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: no known allergies / adverse drug reactions attending: chief complaint: progressive sob major surgical or invasive procedure: left heart catheterization history of present illness: 85 y.o. with history of chf unkown ef who recently stopped taking her medications admitted with increasing progressive sob at osh who was transferred to for catheterization and work-up for cad. . patient was reports that she has been developing sob over the past everal weeks, finding herself panting, which is not her baseline. she reports an occassional cough that is not productive. she denies fevers, chills. she reports getting up in the middle of the night to catch her breath, 1 episode/night. the patient reports that she has not had increasing frequency of of pnd. denies orthopnea. denies le edema or weight gain. in addition to sob, the patient reports weakness and inability to push a vaccuum cleaner, a normal activity of hers also within the time frame of when she developed sob. she denies chest pain accompanying her sob. . patient reports that she had stopped medication a couple of weeks prior as she could not afford them. during this time, the patient was progressively short of breath. . she presented to the osh ed with sob because it was not improving. cxr at osh showed cardiomegaly and possible rll pna. ct of the chest was also done that showed pna with and effusion. intial wbc of 19 on presentation to osh, today on transfer wbc down to 13. she was started on levaquin po qhs and received 2 doses. patient s/p thoracentesis where 1200cc fluid was drained. the patient was also treated with iv 40mg lasix. during her hospitalization, she also had non-sustained vt (27-beats) on telemetry, which was asymptomatic. patient's shortness of breath continued and for further work-up the patient underwent a persantine stress which showed an old imi, moderate inferior wall ishcemia and an ef 22%. troponin were trended through hospitalization at osh and is as follows: 0.08, 0.13, 0.16, 0.14, and 0.1. . patient was transferred to cath lab for further work-up of shortness of breath. cardiac catheterization was significant for 80% lcx, 50% lad and 40% lesion to rca; however no intervention was done as the patient complained of arm pain during the procedure. . on arrival to the floor, patient reports feeling tired from the events of the day. denies cp and sob. . review of systems on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. heart failure history - presumed etiology: ischemic; persantine stress today revealing old imi, moderate inferior wall ischemia - systolic chf - last known ef in year: 22% on persantine stress test ; otherwise unknown - when was the last known hf admission: unknown - known ??????dry?????? or ??????baseline?????? bnp: unknown . 2. cardiac history: - cardiac equivalents or risk factors: (-)diabetes, (-)dyslipidemia, (-)hypertension, (-)current smoking, (-)family history of cad, (-)peripheral arterial disease, (-)stroke - anatomy: native - percutaneous coronary interventions: none - pacing/icd: none - arrhythmias: no prior history - history of cardiotoxic chemotherapy: doxorubicin, trastuzumab- none - thoracic radiation for cancer: none . other past medical history: --?chronic kidney disease, baseline serum creatinine 1.4 social history: - tobacco history: quit 60 years ago; smoked pack per week. - etoh: 1 glass of wine per night - illicit drugs: denies - activity: walks independently around the house. able to dress and bathe herself. she also cooks for herself and her bills. - social support: grandsons - lives at home with her oldest grandson. family history: patient reports htn in father and chf in her mother. there is no documented family history of premature atherosclerotic cardiovascular disease, sudden death, hypertrophic cardiomyopathy, or inborn errors of metabolism affecting the cardiovascular system. physical exam: admission physical exam: dry wt: unknown admission weight: 129 pounds t= 97.4 bp = 123/71 pulse pressure pulse 56 rr and o2 sat: 18; 100% on 2l via nc . general: alert, oriented, no acute distress heent: perrl, eomi sclera anicteric, mmm, oropharynx clear neck: jvp is * cm water, with positive hepatojugular reflux, carotid pulsations normal lungs: crackles at the right and left lung bases anteriorly without wheezes. nml work of breathing. cv: irregular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, diffusely tender to palpation across the abdomen, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: trace bilateral lower extremity edema up to 8-cm above the medial malleolus pn the right; no pitting edema of the lle appreciated. no chronic venous stasis changes with hyperpigmentation and stasis dermatitis; warm, well perfused, 2+ pulses, no clubbing, cyanosis neuro: cn??????s intact, motor function grossly normal, no notable focal neuro deficits, mood and affect are appropriate . discharge physical exam: 97.7 124/59 (sbp 90s-160s) 72 16 97%ra fs 85, 160, 186, 122 i/o: 800/700 general: patient lying in bed in nad heent: mmm. eomi. neck: jvp = 8cm h20 cv: regular rate and rhythm. no murmurs, rubs, or gallops. lungs: no wheeze, rhonchi. trace crackles b/l. decreased lung sounds at the very base of r lung. nml work of breathing. abd: nabs+. soft. very mildly tender diffusely. no rebound. ext: 1+ edema of the le to the mid-shins. pt w/ large ecchymosis on rue, and large, solid hematoma around proximal biceps, painful to palpation. neuro: alert and oriented x3; cn ii-xii w/out defect; speech fluent and pt follows commands; no gross abnormalities on strength testing pertinent results: admission labs: 07:45am blood wbc-13.6* rbc-4.80 hgb-14.5 hct-44.1 mcv-92 mch-30.1 mchc-32.7 rdw-14.3 plt ct-154 09:04pm blood glucose-146* urean-39* creat-1.1 na-142 k-3.6 cl-103 hco3-28 angap-15 07:45am blood ck(cpk)-57 07:45am blood ck-mb-8 ctropnt-0.10* 09:04pm blood probnp-* 09:04pm blood calcium-8.1* phos-3.2 mg-1.8 . pertinent interval labs: 03:55am blood wbc-13.4* rbc-4.99 hgb-14.7 hct-47.3 mcv-95 mch-29.5 mchc-31.1 rdw-14.2 plt ct-230 03:44pm blood wbc-10.6 rbc-4.60 hgb-13.7 hct-43.6 mcv-95 mch-29.8 mchc-31.5 rdw-13.9 plt ct-265 07:37am blood wbc-8.8 rbc-4.30 hgb-12.7 hct-40.5 mcv-94 mch-29.6 mchc-31.4 rdw-14.3 plt ct-277 09:35am blood wbc-8.5 rbc-4.35 hgb-13.4 hct-41.3 mcv-95 mch-30.9 mchc-32.5 rdw-13.9 plt ct-332 03:28am blood pt-14.1* ptt-77.0* inr(pt)-1.3* 03:40am blood pt-13.7* ptt-90.7* inr(pt)-1.3* 03:55am blood ptt-75.5* 03:12am blood pt-11.0 ptt-67.7* inr(pt)-1.0 12:33am blood ptt-58.6* 09:35am blood pt-11.3 ptt-28.9 inr(pt)-1.0 07:45pm blood glucose-210* urean-38* creat-1.3* na-138 k-3.6 cl-97 hco3-33* angap-12 02:58pm blood glucose-116* urean-38* creat-1.2* na-140 k-4.1 cl-101 hco3-27 angap-16 06:00am blood glucose-101* urean-32* creat-1.0 na-139 k-3.6 cl-101 hco3-31 angap-11 09:35am blood glucose-202* urean-31* creat-0.9 na-140 k-3.9 cl-102 hco3-29 angap-13 07:26am blood pt-11.1 ptt-30.2 inr(pt)-1.0 07:26am blood glucose-98 urean-34* creat-0.8 na-143 k-4.1 cl-106 hco3-32 angap-9 09:04pm blood probnp-* 07:45am blood ck-mb-8 ctropnt-0.10* 07:53pm blood ck-mb-2 ctropnt-0.31* 03:40am blood calcium-7.9* phos-3.0 mg-2.0 09:35am blood calcium-8.7 phos-2.9 mg-1.9 07:45am blood triglyc-135 hdl-25 chol/hd-4.8 ldlcalc-69 06:00am blood tsh-4.5* 06:00am blood t4-8.3 03:08pm blood lactate-1.9 . urine: 11:07pm urine hours-random urean-603 creat-48 na-57 k-40 cl-67 11:07pm urine osmolal-531 histoplasma antigen urine 3.2 h < 2.0 eia units reference range for histoplasma antigen urine: < 2.0 . . . . negative 2.0 - 4.0 . . . . weak positive > 4.0 . . . . positive . pleural fluid: 05:25pm pleural wbc-700* rbc-3533* polys-48* lymphs-26* monos-0 meso-9* macro-17* 05:25pm pleural totprot-2.2 glucose-143 ld(ldh)-225 amylase-27 pleural fluid negative for malignant cells test result reference range/units adenosine deaminase, pleural 2.8 <9.2 u/l fluid reference interval: adenosine deaminase tuberculosis mean 92.1 u/l metastatic malignancies mean 23.3 u/l mesotheliomas mean 34.9 u/l pulmonary embolism mean 23.8 u/l lymphoma mean 64.3 u/l . imaging: echo : the left atrium is mildly dilated. the left atrium is elongated. the right atrium is moderately dilated. the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is severely depressed lvef= 20 %) secondary to akinesis of the basal to distal inferior and infero-lateral walls, apex and moderate hypokinesis of the remaining segments. a moderate sized thrombus (1.1 cm x 1.4 cm) is seen in the apex of the left ventricle. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a very small pericardial effusion located predominantly along the left ventricular infero-lateral base. there are no echocardiographic signs of tamponade. impression: severe focal and global left ventricular systolic dysfunction c/w multivessel cad. evidence of lv apical thrombus. moderate pulmonary artery systolic hypertension. . coronary catheterization : 1. selective coronary angiography of this right dominant system demonstrated two vessel coronary disease. the lmca was patent. the lad had a proximal 50% lesion. the ramus was patent. the lcx had a proximal 80% stenosis. the rca had mild diffuse plaquing. it was very difficult to engage the rca and the lmca via right radial access. both arteries were eventually engaged with an al1 catheter. 2. limited resting hemodynamics revealed normotension. final diagnosis: 1. two vessel coronary artery disease. 2. return after treatment of her pneumonia for pci of the lcx in about 2 weeks via femoral access. . ct chest non-con (): technique: mdct axial images were obtained through the chest, abdomen, and pelvis with the administration of iv contrast. multiplanar reformats were generated and reviewed. ct of the chest: a 6-mm hypodensity in the right lobe of the thyroid gland may be further evaluated with a thyroid ultrasound. atherosclerotic calcifications are noted within the abdominal aorta. the thoracic aorta as well as the pulmonary vasculature appear unremarkable within limitation of non-contrast technique. atherosclerotic calcifications are noted within the coronary artery. calcified mitral annulus is identified. mild atherosclerotic calcifications are noted within the thoracic aorta. calcified mediastinal lymph nodes are noted but do not meet ct size criteria for pathology measuring up to 5 mm in the right paratracheal station (series 2, image 24). a left calcified hilar lymph node measures 9 mm in short axis diameter (series 2, image 25). axillary lymph nodes do not meet ct size criteria for pathology. layering, nonhemorrhagic, pleural effusions are moderate volume on the right and small on the left, with adjacent compressive atelectasis. no nodulation is noted on the pleural surfaces. moderate cardiomegaly with a small pericardial effusion is present. the airways are patent to the subsegmental levels. fluid along the fissure is noted (series 2, 40). large calcified nodules in the upper and lower right lungs measuring 20 (series 2, 23) and 36 mm (2, 39) are calcified granulomas. additional smaller granuloma is noted within the left lung (series 2, image 23) measuring 8 mm. this study is not optimized for subdiaphragmatic evaluation. within this limitation, trace perihepatic free fluid is present. scattered calcifications within the liver and spleen consistent with granulomas are noted. visualized osseous structures show no focal lytic or sclerotic lesions. impression: 1. layering, nonhemorrhagic, pleural effusions are moderate volume on the right and small on the left, responsible for compressive atelectasis. 2. moderate cardiomegaly with small pericardial effusion. 3. trace perihepatic free fluid. 4. large calcified granulomas and smaller calcified granulomas in the liver and the spleen reflect priof granulomatous infection. no indication of active infection or malignancy in the chest. ct brain perfusion (): ct head: there is no acute intracranial hemorrhage, infarction, edema, or mass effect seen. there are extensive bilateral periventricular hypodensities which may represent small vessel ischemic disease. ventricles and sulci are otherwise age appropriate. visualized orbits, paranasal sinuses, and mastoid air cells are unremarkable. there is no fracture seen. ct perfusion: there is an area of increased mean transit time in the right parietal lobe in the distribution of the posterior division of right middle cerebral arterial territory with no corresponding decrease in blood volume. cta head and neck: atherosclerotic calcifications are seen in the aortic arch and visualized descending thoracic aorta. there is a normal three-vessel takeoff from the aortic arch. bilateral common carotid arteries, internal carotid arteries, and vertebral arteries are patent with no evidence of stenosis, occlusion, dissection, or pseudoaneurysm formation. atherosclerotic calcifications are seen at the carotid bulbs bilaterally without significant stenosis. bilateral vertebral arteries are small in size. bilateral vertebral artery origins are patent. there is an effective pica termination of the right vertebral artery. there is a persistent trigeminal artery seen on the right side. there are atherosclerotic calcifications seen in bilateral cavernous icas. bilateral intracranial internal carotid arteries, vertebrobasilar arteries, and their major branches are otherwise patent with no evidence of stenosis, occlusion, dissection, or aneurysm formation. there is pleural effusion on the right side with large calcified granuloma in right upper lobe, better evaluated on recent chest ct study. impression: 1. increased mean transit time in the right parietal lobe without corresponding decrease in blood volume, concerning for an area of acute ischemia. 2. no major vascular occlusion identified on the cta. note made of persistent trigeminal artery on the right side. 3. unremarkable cta of the neck. 4. right pleural effusion and calcified right upper lobe granuloma better evaluated on recent chest ct study. . mr head (): technique: sagittal t1, axial t2, flair, diffusion-weighted and gradient echo images through the brain were obtained without contrast. patient was on tuberculosis precautions and wearing a mask, causing marked susceptibility artifacts. findings: there are multiple foci of slow diffusion seen in the right frontal and parietal lobes. there is no acute intracranial hemorrhage, mass effect or edema seen. there are extensive periventricular white matter hyperintensities on t2 and flair images, likely represent small vessel ischemic disease. the intracranial flow voids are preserved. no hydrocephalus or midline shift. impression: 1. multiple small foci of slow diffusion in right frontal and parietal lobes concerning for acute infarcts. no acute intracranial hemorrhage is seen. the study is limited because of extensive susceptibility artifacts. 2. small vessel ischemic disease. . cxr (): lung volumes have improved. minimal interstitial edema and small right pleural effusion persists. heart size top normal. large benign calcification in the right lung could be hamartoma or granuloma. . thyroid u/s (): findings: the right lobe of the thyroid measures 2.2 x 1.8 x 4.0 cm and the left lobe measures 2.0 x 1.9 x 4.1 cm. the background thyroid architecture is unremarkable and the gland is not hypervascular. a small spongy nodule seen at the upper pole of the right lobe measuring 1.6 x 0.8 x 1.5 cm. a similar-appearing nodule seen at the upper pole of the left lobe measuring 1.5 x 1.0 x 1.1 cm. no dominant nodule is identified. impression: no dominant nodule is seen in the thyroid. small bilateral spongy nodules do not demonstrate any concerning features. no fna is required. . r shoulder 2-views (): there is severe diffuse osteopenia. no fracture or dislocation is detected involving the right shoulder. there is marked narrowing of the acromiohumeral distance, with essentially complete effacement of the rotator cuff outlet. this appearance is compatible with a chronic rotator cuff tear. a large inferior acromial spur is present. there is superior subluxation of the humeral head with respect to the glenoid. there is a slightly exophytic ovoid sclerotic focus centered on the posterior cortex of the proximal diaphysis of the humerus, of uncertain etiology or significance. of note, there are several rounded calcified densities overlying the right lung, the two largest measure 1.8 and 2.7 cm respectively. these are also seen on radiographs and on a chest ct both dated and were thought to represent large granulomas pm the ct scan report. impression: 1. findings consistent with chronic rotator cuff tear. no acute fracture or dislocation identified. 2. ovoid sclerotic density centered in the posterior cortex of the proximal humeral diaphysis, slightly exophytic. this is of uncertain etiology or significance. no clearly aggressive features. ? sequela of old trauma. in the absence of known malignancy, sclerotic metastasis is considered much less likely. clinical correlation and, if indicated, follow-up radiograph in months could help to assess for stability. . ruq u/s (): findings: transverse and sagittal images were obtained of the palpable lump in the upper right arm. at this site, there is a complex solid hypoechoic mass which measures 6.4 x 3.3 x 4.0 cm. this mass is avascular on color doppler imaging and most likely represents a hematoma. impression: large solid avascular mass in the right upper extremity, which most likely represents a hematoma. . micro/send-out: coccidioides antibody, id negative negative cryptococcal antigen (final ): cryptococcal antigen not detected. 5:25 pm pleural 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 blood 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. test result reference range/units yeast phase antibody <1:8 <1:8 mycelial phase antibody <1:8 <1:8 interpretive criteria: <1:8 - antibody not detected =============================================== test result reference range/units quantiferon(r)-tuberculosis indeterminate a negative verified by repeat analysis. results are indeterminate for response to esat-6,tb7.7 or cfp-10 test antigens. test result reference range/units nil 0.01 iu/ml mitogen-nil 0.15 iu/ml tuberculosis-nil 0.00 iu/ml brief hospital course: ========================== brief patient summary ========================== 85f with chf, cad, transfered from osh for cardiac cath on in the of setting worsening sob/doe, which demonstrated two-vessel disease, iv heparin transitioned to warfarin/lovenox bridge for lv thrombus identified on tte and developed a cva event on with now resolving r gaze deviation, l hemiplegia. the patient also has cap w/ associated pleural effusion s/p thoracentesis and e/o granulomatous lung/liver/mediastinum lesions, which is chronic. ========================== active issues ========================== #. acute systolic congestive heart failure: patient presented in a hypervolemic state with crackles at the lung bases bilaterally, anteriorly and trace pitting edema of right le. patient's persantine stress test at the outside hospital showed an ef 22% and evidence of old inferior mi and moderate inferior wall ischemia. the patient was diuresed with 80mg iv lasix with diuresis of approximately 1.5 liters of fluid daily. discussion with the patient's outpatient cardiologist revealed that the patient had a dilated cardiomyopathy in the setting of a stressful situation that then resolved. prior echos as an outpatient did not show evidence of ischemia. patient's bnp was upon admission. she was transitioned to oral lasix 40mg qd approximately three days prior to discharge. she maintained a net neutral fluid balance for the past three days prior to discharge. the patient has discharge follow-up with her outpatient cardiologist. . #. coronary artery disease: patient found to have disease in the lcx, lad, and rca on left heart catheterization upon presentation. no intervention was done as the patient did not tolerate the procedure well secondary to respiratory status. decision currently has been made to medically optimize the patient and have patient return for catheterization with intervention as an outpatient. she was restarted on metoprolol 37.5mg three times daily, aspirin 81mg daily (started on days after stroke), atorvastatin 40mg daily, and lisinopril 5mg daily. . # left ventricular thrombus and cardioembolic stroke: patient was noted to have a left ventricular thrombus present on tte . patient was initiated on anticoagulation with warfarin, bridging with iv heparin, given risk of cardioembolic stroke. daily inr was checked. goal inr 2.0-3.0. on , she was noted to have a r gaze deviation and left hemiplegia. a code stroke was called. a cta head/neck and ctp were performed showing an increased mtt suggestive of a large ischemic area. she was supratherapeutic on heparin at this time, though (this was held and allowed to trend down to the therapeutic range). an mri revealed small punctate dwi/adc changes suggesting acute cerebral ischemia, predominantly in the r hemisphere. given these small strokes, the recommendation from the stroke service is to delay pci/stenting for at least one week (ideally weeks) to minimize the risk of hemorrhagic conversion when giving dual antiplatelet therapy and therapeutic anticoagulation. the patient spent a brief amount of time in the neurosurgical icu, and then was called out to the general medicine floor. her neurologic deficits lessened with only mild l hemiparesis (4+ to 5- in an upper motor neuron pattern) on , and nearly completely resolved by time of discharge. warfarin was added, and patient was bridged with lovenox (as opposed to continuing heparin drip). the patient's inr subtherapeutic on disposition, thus bridging continued. on day of discharge, inr was 1.0. the patient was restarted on aspirin 81 mg for cardioprotective purposes on (per neurology, recommended 7 d post-stroke until restarting aspirin. . # chronic granulomas: the patient had significant evidence of bilateral granulomas in lungs, liver, mediastinum are chronic (>10yrs old, from ) based upon prior imaging that was ascertained from previous hospitals. prior to ascertaining that these granulomas were chronic, we attempted to get induced sputums for a rule-out of tuberculosis, but sputums unable to be induced by respiratory therapy. pt had a adenosine deaminase that was very low, and not suggestive of tuberculosis in pleural fluid. the patient had a ppd that was read as negative. quantiferon was indeterminate. in the setting of no symptoms such as fever, cough, we had very low likelihood that this was active tuberculosis. the patient had a weakly positive histoplasma urine antigen and the patient said she spent a lot of time on farms growing up. the patient's serum histoplasma antibody, coccidio and cryptococcal antigens were all negative. we repeated a histoplasma urine antigen, to be used by infectious disease at follow-up. chronic granulomas are likely secondary to a chronic or old process, and no intervention since patient is asymptomatic. pleural effusion likely secondary to another process (chf). the patient has outpatient follow-up with pulmonary and infectious disease. . # non-sustained ventricular tachycardia: patient with 27 beats of asymptomatic nsvt at the outside hospital, prior to transfer. patient was monitored on telemetry through her admission at , and would have runs of nsvt that were asymptomatic. patient's runs of nsvt were thought to be due to ventricular stretch in the setting of poor systolic function. patient's electrolytes were monitored and repleted as needed. the patient was placed on metoprolol 37.5mg tid. patient was asymptomatic through these episodes, and they were thought to be secondary to underlying systolic chf. with diuresis, the patient's frequency of nsvt decreased. . # community-acquired pneumonia: patient was initiated on treatment for cap at osh for possible pneumonia. received 2 days of levofloxacin prior to presentation at . reivew of records from osh showing cloudy appearance with 450wbc of the pleural fluid. pleural fluid cultures from hospital- showing vr-enterococcus spp in the broth culture, though no growth in plates. infectious disease was consulted given the unusual bacteria isolated from culture. under infectious disease's guidance, the patient was transitioned to antibiotic treatment for community-acquired pneumonia with ceftiraxone and azithromycin. the patient completed her course of antibiotics on . the patient also underwent repeat throacentesis, the cultures was which were negative for any growth, and transudative in nature (believed to be secondary to chf). given that the patient was not treated with any antibiotics that would treat vre while at osh or here, and no growth on our pleural fluid cultures, we believe this "broth" finding may have been a contaminant. . # rue hematoma: on approx , it was noticed that the patient had a significant, likely intramuscular, hematoma near the proximal humerus area. she also has a significant ecchymosis on rue. no trauma was noted by pt throughout hospitalization. the patient had a xray and ultrasound, consistent w/ hematoma and some chronic changes. pt was treated w/ elevation and warm packs on hematoma. pt was neurovascularly intact in rue. . #. acute kidney injury: patient presented from osh with labs there showing a serum creatinine of 1.4. patient's serum creatinine upon presentation to was 1.0. patient's acute kidney injury likely due to pre-renal etiology, possibly secondary to underlying systolic heart failure. patient's serum creatinine ranged from 0.9 - 1.3 through the admission. . #. hypertension: patient denies, though the patient's history of hypertension was confirmed with her outpatient cardiologist. patient was continued on metoprolol and lisinopril through her inpatient hospitalization, without episodes of hypertension. holding parameters were for her anti-hypertensives. . . ============================= transitional issues ============================= 1. follow-up with outpatient cardiologist for both chf and regarding intervention for known coronary artery disease. 2. follow-up with neurology 3. follow-up with pcp once pt returns from 4. follow-up with pulmonary disease 5. follow-up with infectious disease 6. f/u tfts as an outpatient 7. ovoid sclerotic density centered in the posterior cortex of the proximal humeral diaphysis, slightly exophytic. this is of uncertain etiology or significance. no clearly aggressive features. ? sequela of old trauma. in the absence of known malignancy, sclerotic metastasis is considered much less likely. clinical correlation and, if indicated, follow-up radiograph in months could help to assess for stability. 8. pcp and infectious disease to follow-up repeat urine histoplasma medications on admission: --lopressor 25mg --zocor 40mg qday --asa 81mg daily --lisinopril 5mg daily discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day): hold for sbp < 90 or hr < 60. 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily): hold for sbp < 90. 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily): hold for sbp < 90. 4. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. warfarin 4 mg tablet sig: one (1) tablet po once daily at 4 pm: please titrate inr to . 6. docusate sodium 100 mg capsule sig: one (1) capsule po daily (daily) as needed for constipation. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. enoxaparin 60 mg/0.6 ml syringe sig: sixty (60) mg subcutaneous (2 times a day): please continue until inr therapeutic. . 9. outpatient lab work please draw basic metabolic panel and inr on , and fax to md on call. 10. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: nursing and rehab center - discharge diagnosis: primary diagnosis: cerebrovascular accident (stroke) systolic heart failure coronary artery disease community-acquired pnuemonia granulomatous lung disease not otherwise specified secondary diagnoses: chronic kidney disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mrs. , it was a pleasure taking care of you during your hospitalization at medical center. you were hospitalized because of shortness of breath and need for a cardiology procedure. while you were in the hospital, we treated you for a pneumonia, we further characterized your heart disease with a cardiac catheterization. you also unfortunately had a stroke, which you recovered significantly from. please take all medications as instructed. keep all hospital follow-up appointments. your hospital follow-up appointments are listed below followup instructions: name: , md location: medical center-cardiac arrhythmia address: , ma phone: appointment: monday 1:00pm department: infectious disease when: friday at 9:00 am with: , md building: lm bldg () campus: west best parking: garage department: pulmonary function lab when: monday at 8:40 am with: pulmonary function lab building: campus: east best parking: garage department: medical specialties/pulmonary when: monday at 9:00 am with: rn/dr. building: sc clinical ctr campus: east best parking: garage department: neurology when: tuesday at 5:00 pm with: , m.d. building: campus: east best parking: garage procedure: coronary arteriography using two catheters left heart cardiac catheterization thoracentesis diagnoses: pneumonia, organism unspecified hyperpotassemia subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery unspecified pleural effusion congestive heart failure, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified chronic kidney disease, unspecified other specified forms of chronic ischemic heart disease other specified cardiac dysrhythmias postinflammatory pulmonary fibrosis other sequelae of chronic liver disease personal history of noncompliance with medical treatment, presenting hazards to health nontraumatic hematoma of soft tissue cerebral embolism with cerebral infarction do not resuscitate status acute on chronic systolic heart failure hemiplegia, unspecified, affecting unspecified side other diseases of spleen other diseases of mediastinum, not elsewhere classified 

Answer: The patient is high likely exposed to