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: dyspnea, delirium major surgical or invasive procedure: none history of present illness: 71 y/o m with nsclc, hep c, copd, and remote etoh/ivd/tobacco abuse who was brought to the ed from his rehab center for agitation, in the setting of ~3 weeks of reported delirium, that has improved somewhat on a new risperidone. he reportedly refused antibiotics when awoken, then became agitated and combative at midnight last night, throwing objects around his room and screaming at his caretakers. swung his cane at staff members. chemical restraint with haldol was unsuccessful. he was placed on a section 12 by psychiatry and sent to the ed for further management. . in the ed inital vitals were 98.2, 112, 110/77, 20, 98% 3l nc. exam notable for +2 symmetric pitting edema to the thighs. labs included normal wbc and stable hgb/hct, elevated creatinine to 1.9 (baseline ~1.1), normal lfts other than alkaline phosphatase 131, inr 1.3, bnp >6700, troponin 0.04, and a urinalysis with moderate leukocytes, 6 wbc/hpf, but no bacteria. lactate was 1.5. head ct was negative for acute process but +clivus bony lucency, as previously seen on mri. cxr showed new bilateral pleural effusions and worsening right sided opacities concerning for infection and/or progression of malignancy. he had a 1:1 sitter for possible self-injurious gestures with oxygen tubing. solumedrol 125 mg iv, combivent nebs x3, ampcillin 1g, vancomycin 1g, cefepime 2g, levofloxacin 750 mg, and enoxaparin 80 mg. vitals prior to transfer were 108, 121/90, 28, 100% (supplemental o2 not recorded). . on the floor, he has no complaints other than ongoing chronic low back pain. denies chest pain, dyspnea, cough, palpitations, fevers, chills, leg pain, or constipation. is hungry and is asking for food. . omr note written by dr. of hematology/oncology on indicates that the patient had been declining clinically at rehab, including worsening renal function, dyspnea and performance status, and his sister at the time) had decided to refocus his care on comfort measures. . review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies wheezing. denies nausea, vomiting, diarrhea, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: oncologic history: - : presented to an outside hospital with severe back pain, with cxr showing right upper lobe lung mass. pet scan revealed fdg avidity at the periphery of the mass, with an fdg-avid paratracheal lymph node - cervical mediastinoscopy, multiple lymph nodes neg for malignancy (report not available). - transthoracic biopsy at , nondiagnostic. pt declined rul lobectomy - new moderate right-sided pleural effusion; right lung nodule increased from 6.6 to 7.7 cm and was again noted to have broad contact with the chest wall - : dr. again saw the patient and recommended a right thoracotomy and rul lobectomy. surgery was scheduled but was canceled by the patient - chest ct revealed further increase in the known necrotic rul lung mass, now measuring 8.1 x 7.5 cm. it was in direct contact with the peripheral pleural surface, with loss of a normal intercostal fat plane between the adjacent ribs, suggesting possible chest wall invasion. the epicenter of the mass was in the right upper lobe but crossed the fissure to extend into the adjacent right middle lobe. prevascular and right paratracheal and precarinal lymph nodes were again demonstrated, with a slight interval increase in the size of the enlarged precarinal node. in the multidisciplinary thoracic oncology conference, it was felt that the patient would most likely require a right pneumonectomy given the extent of his tumor. however, due to his poor pulmonary function, with a dlco of 60%, it was felt that he would not tolerate a pneumonectomy. - : a repeat bronchoscopy and endobronchial ultrasound was performed for diagnostic purposes, with a biopsy of the right upper lobe mass revealing poorly differentiated adenocarcinoma with immunostains positive for p63 and ck7 (weak), negative for ttf-1. squamous cell carcinoma was favored. a transbronchial needle aspiration of station 7, 4r, and r11 lymph nodes revealed no malignant cells. two sets of washings were negative, but brushings were positive for malignant cells. - : a repeat pet scan demonstrated no evidence of bony metastatic disease. the previously biopsy-negative right paratracheal lymph node was noted to be fdg-avid (suv 4.7). thus, the patient was felt to have likely stage iiia (t3n1m0) squamous cell carcinoma of the lung. - : the patient began weekly carboplatin (auc 2) and paclitaxel (50mg/m2) given concurrently with radiation therapy. finished chemoradiation in , last dose of chemo on . required prednisone taper due to severe radiation pneumonitis. . ct torso showing a mildly enlarged cavitating lesion in the right upper lobe, which is now 6.5 x 4.4 cm, increased from 6.3 x 3.7 cm. there are two new right hilar lymph nodes, both measuring approximately 2 cm . -: treated with carboplatin, gemcitabine, with doses intermittently held for lft abnormalities. : ct chest without contrast showing slightly enlarged right upper lung mass, measuring 7.5 x 5.2 cm, with slightly enlarged soft tissue component at the right middle lobe bronchus, measuring 3 x 3 cm : palliative chemo with taxotere, with doses held due to dehydration and cytopenias. . : admitted to because of uncontrolled nausea and emesis, dehydration, volume depletion. patient on : discontinue taxotere due to intolerable nausea, emesis, decreased appetite . : chemo with vinorelbine . ct chest: decreased size in primary mass, measuring 6.5 x 4.1 cm, as compared to 7.4 x 5.2 cm previously. the previously noted thickening of the medial wall has also decreased, measuring 2.1 x 1.9 cm compared to 2.9 x 1.6 cm previously. no new nodules are present. severe traction bronchiectasis related to post-radiation therapy changes has mildly improved. severe paraseptal emphysema is unchanged. . : hospitalized at for enterococcus mitral valve endocarditis and t12-l1 diskitis/osteomyelitis. treated initially with ampicillin and gentamicin, with gentamicin discontinued due to impaired renal function. six-week course of ampicillin is scheduled to end on . he had a right internal jugular and axillary vein thrombosis, associated with his right sided port-a-cath, which was initially diagnosed at on , and has continued on lovenox for treatment. he was seen by cardiology for nsvt, mitral valve endocarditis, and was started on metoprolol for rate control. he was seen by cardiothoracic surgery for consideration of mitral valve repair, with outpatient followup planned. he was discharged to the macu unit of rehab, where he has been since discharge. . ct angio of the chest showed a 4.5 cm x 3 cm thick-walled mixed solid and cystic structure in the right upper lobe corresponding to interval necrosis of treated tumor. there is no pulmonary embolism. severe paraseptal emphysema was seen, along with post-radiation changes in the right lung. there is an enlarged and irregular substernal thyroid goiter, with features concerning for malignancy. mri of the l-spine showed resolution of previously noted diskitis and osteomyelitis at t12 and l1. there were multilevel degenerative changes throughout the lumbar spine, stable, causing moderate-to-severe canal stenosis. mri of the brain showed no intraparenchymal findings, but there was a new clivus mass, most likely representing an osseous metastasis. . other pmhx: -enterococcus mitral valve endocarditis -hepatitis c, acquired in prison, not treated, stable. -hx intravenous drug use, stable. -history of gunshot wound for which a large abdominal surgery was required -hypertension, stable. -emphysema/copd -right internal jugular and axillary vein thrombosis, associated with his right sided port-a-cath social history: ppd x 30 years currently still smoking, social alcohol use, history iv heroin use and cocaine use. family history: hypertension in mother. diabetes in father and aunt. other known family history. physical exam: admission physical exam: vitals: t:97.6 bp:145/107 p:109 r:25 o2:96% 4l nc general: alert, oriented to his own name and dob, oriented to "right before " but cannot provide month, date, or year, no acute distress heent: no conjunctival icterus/injection/pallor, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: diffuse rhonchi and wheeze, decreased breath sounds right base. mildly increased work of breathing and use of accessory muscles cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: 2+ edema to knees bilaterally, symmetric. warm, well perfused discharge physical exam vitals: tmax:98.7 bp:90-110/52-80 p:103-113 r:20-24 o2:94-97% 4l nc general: aox3, comfortable and pleasant gentelman heent: no conjunctival icterus/injection/pallor, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: diffuse rhonchi and wheeze, decreased breath sounds right base. no use of accessory muscles cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: 2+ edema to knees bilaterally, symmetric. warm, well perfused pertinent results: admssion labs: 11:31am blood wbc-5.6 rbc-3.42* hgb-9.4* hct-30.6* mcv-89 mch-27.4 mchc-30.6* rdw-16.4* plt ct-216 11:31am blood neuts-75.2* lymphs-17.2* monos-6.6 eos-0.7 baso-0.3 11:31am blood pt-15.0* ptt-47.1* inr(pt)-1.3* 11:31am blood glucose-116* urean-21* creat-1.9* na-139 k-4.7 cl-102 hco3-28 angap-14 11:31am blood alt-12 ast-23 alkphos-131* totbili-0.4 11:31am blood ctropnt-0.04* probnp-6765* 12:07am blood ctropnt-0.01 05:23am blood ctropnt-0.01 05:23am blood calcium-9.0 phos-4.0 mg-1.8 micro data: imaging: ct head w/o contrast () no acute intracranial process. clivus bony lucency better assessed on the prior mri, possibly representing a site of osseous metastatic disease. . pcxr () interval development of bilateral pleural effusions with increasing consolidation in the right mid and lower lung which could represent infection and/or tumor progression. probable pulmonary edema involving the left lung, though superimposed pneumonia or progression of metastatic disease is difficult to exclude. . venous dup upper ext unilateral left () sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | clindamycin-----------<=0.25 s r erythromycin---------- =>8 r =>8 r gentamicin------------ 8 i =>16 r levofloxacin---------- =>8 r =>8 r oxacillin------------- =>4 r =>4 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- 2 s 2 s vancomycin------------ 2 s 2 s echocardiography report , portable tte (complete) done at 11:52:49 am final referring physician information , pulmonary, critical care & , e/ks-b23 , status: inpatient dob: age (years): 71 m hgt (in): 67 bp (mm hg): 109/83 wgt (lb): 190 hr (bpm): 106 bsa (m2): 1.98 m2 indication: endocarditis. left ventricular function. right ventricular function. icd-9 codes: 424.90, 427.31, 785.0, 423.9, 424.0, 424.3, 424.2 test information date/time: at 11:52 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: east micu contrast: none tech quality: adequate tape #: 2011e055-0:24 machine: vivid echocardiographic measurements results measurements normal range left atrium - four chamber length: *6.9 cm <= 5.2 cm right atrium - four chamber length: *6.5 cm <= 5.0 cm left ventricle - septal wall thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 3.2 cm <= 5.6 cm left ventricle - ejection fraction: >= 60% >= 55% left ventricle - stroke volume: 55 ml/beat left ventricle - cardiac output: 5.87 l/min left ventricle - cardiac index: 2.97 >= 2.0 l/min/m2 left ventricle - lateral peak e': 0.12 m/s > 0.08 m/s left ventricle - septal peak e': 0.09 m/s > 0.08 m/s left ventricle - ratio e/e': *17 < 15 aorta - sinus level: *3.8 cm <= 3.6 cm aortic valve - peak velocity: 1.1 m/sec <= 2.0 m/sec aortic valve - lvot vti: 16 aortic valve - lvot diam: 2.1 cm mitral valve - e wave: 1.8 m/sec mitral valve - e wave deceleration time: 195 ms 140-250 ms tr gradient (+ ra = pasp): *29 to 50 mm hg <= 25 mm hg findings this study was compared to the prior study of . left atrium: dilated la. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). no resting lvot gradient. right ventricle: mildly dilated rv cavity. mild global rv free wall hypokinesis. aorta: mildy dilated aortic root. aortic valve: mildly thickened aortic valve leaflets (3). no as. significant ar, but cannot be quantified. mitral valve: mildly thickened mitral valve leaflets. probable vegetation on mitral valve. moderate to severe (3+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not visualized. no ps. physiologic pr. pericardium: moderate pericardial effusion. no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. general comments: resting tachycardia (hr>100bpm). conclusions the left atrium is dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. significant aortic regurgitation is present, but cannot be quantified. the mitral valve leaflets are mildly thickened. there is a probable vegetation on the mitral valve. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. impression: probable vegetation on the mitral regurgitation. at least moderate-to-severe, eccentrically-directed mitral regurgitation. dilated and hypokinetic right ventricle with moderate to severe pulmonary artery hypertension. moderate circumferential pericardial effusion without evidence of tamponade. compared with the prior study (tee - images reviewed) of and tte of , the previously seen mitral valve vegetation is not well seen on the current study (although is still likely present). the right ventricle appears dilated and hypokinetic. the degree of mitral regurgitation is now at least moderate-to-severe. there is probably aortic regurgitation on the current study (difficult to determine severity). there is a moderate pericardial effusion. findings discussed with dr. at 1430 on day of study. electronically signed by , md, interpreting physician 14:26 ============================================================== brief hospital course: icu course: this is a 71 year old man with a history of enterococcus mv endocarditis with blown posterior mitral leaflet s/p six weeks of ampicillin, continued stay at rehabilitation, who now presents with worsening dyspnea and concern for heart block, found to have gpc blood stream infection in the setting of a mid-line iv catheter. -symptomatic bradycardia: there was a specific concern for conduction disease in the setting of recent endocarditis and current bloodstream infection. cardiology was consulted, and also commented that he may have exacerbation of the bradycardia specifically with increased vagal tone. he was not a candidate for permanent or temporary pacer given his bloodstream infection, and will not be until he completes his course of treatment for his blood stream infection. patient never required pacing in the icu. -bloodstream infection: needs 6 week treament course per id for coag neg staph sensitive to vancomycin, which is current antibiotic choice. presumed source is the midline he came from rehabilitation with, which was pulled. repeat tte showed probably vegetation, though difficult to discern from previous echo findings for endocarditis. tee was not done as he is not a candidate for cardiac surgery (as documented in chart) and the risks of the procedure were felt to outweigh the benefits). instead, he will receive empiric 6 week course for endocarditis. -mitral regurgitation/chf exacerbation: patient was aggressively diuresed and received afterload reduction with imdur and hydralazine. -lung ca/goals of care: patient had recent reversal of code status and was full code on arrival (had previously been ). his sister had been his healthcare proxy and had decided on status given his endstage illness. however, per report, patient found about about this and asked his reverend to take over position of hcp and code status was reverted to full code during admission. at goals of care meeting, decided pt was "no cpr indicated," but would intubate. palliative care and psychiatry (to assess competency) were consulted and assisted as well with goals of care. floor course: # endocarditis/mr: mr. was maintained on vancomycin for a planned total 6 week course. again, mr. tenuous clinical status made him a non-surgical candidate for management of his endocarditis. cardiology was consulted concerning his mr, and the decision was made to diurese him gently with ~500 cc negative. during this diuresis, he became tachycardic to the 140's with a 20 beat run of ventricular tachycardia. his ventricular ectopy was controlled with metoprolol tartrate 6.25 mg . afterload reduction with imdur and hydralazine was continued. # lung ca: given known significant burden of disease on , s/p multiple rounds of chemo, all complicated by side effects. possibly worsened over past two months off treatment. per primary oncologist, hospice and/or comfort focused care seemed to be the best option for his management. . # acute kidney injury: cr rose to 2.1 by discharge which is slightly elevated to that seen on admission. no clear nephrotoxins at this time. was on gentamicin for several weeks which corresponded with creatinine elevation. bun:creatinine ratio was suggestive of intrinsic injury, and patient volume overloaded. u/a was without significant findings or casts reported on sediment. no indications existed for urgent rrt. of note cr was 1.8 upon arrival to the floor, and rose slightly to 2.1 with diuresis. . goals of care: multiple meetings occurred with mr. concerning his goals of care and code status. while comfort focused measures seemed appealing to him, mr. still wished to remain full code. . # agitation: by report, mr. was quite agitated both at rehab as well as during his initial ed course. this agitation required antipsychotic therapy with risperidone and haloperidol, and manifested as suicidal ideation as well as aggressive actions. mr. was quite delerious upon presentation to the icu and was oriented x . with treatment of his endocarditis, mr. became increasingly oriented and less agitated. throughout his 5 day stay on the floor (after being called out to the unit), mr. did not require antipsychotics or restraints. he is alert and oriented x 2, and does not express suicidal ideation or aggression. it is likely that his earlier behavior was a component of delirium in the setting of endocarditis. medications on admission: -ampicillin 1g iv q6h -enoxaparin 80 mg sc q12 -furosemide 20 mg po daily -levalbuterol nebs q6h -morphine sulfate er 15 mg po q12 -mvi 1 tab daily -omeprazole 40 mg daily -risperidone 0.25 mg @ 0830, 1200; 0.5 mg qhs -acetaminophen 650 mg daily -haloperidol 1 mg po and im prn -ipratropium q6hr -oxycodone 2.5 mg po q6h prn discharge medications: . 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) 5,000 unit injection injection tid (3 times a day). 2. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) 3 ml(s) nebulization inhalation every four (4) hours. 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 4. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 5. morphine 15 mg tablet extended release sig: one (1) tablet extended release po q12h (every 12 hours). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. ipratropium bromide 0.02 % solution sig: one (1) 3ml nebulizatio inhalation q6h (every 6 hours) as needed for dyspnea, wheeze. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. hydralazine 10 mg tablet sig: two (2) tablet po q6h (every 6 hours). 10. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q4h (every 4 hours) as needed for cough. 11. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 12. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: two (2) tablet extended release 24 hr po daily (daily). 13. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 14. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 15. metoprolol tartrate 25 mg tablet sig: 0.25 tablet po bid (2 times a day). 16. zofran odt 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 17. furosemide 40 mg iv daily start: in am start on 18. outpatient lab work please obtain serum electrolytes daily (sodium, potassium, chloride, bicarbonate, bun, creatinine, glucose, magnesium, phosphate, calcium) and replete electrolytes as needed. 19. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia: hold for rr < 22, sbp < 90. 20. vancomycin 1500 mg iv q48h start date of vancomycin therapy , planned 6 week course, last date . discharge disposition: extended care facility: - discharge diagnosis: mitral regurgitation with heart failure endocarditis non small cell lung cancer chronic obstructive pulmonary disease hepatitis c discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you at . you were admitted with an infection of your heart known as endocarditis. this infection initially presented itself with changes in your mental status, and cultures from your blood indicate that a bug called staph aureas is causing the infection. we are treating this with a drug called vancomycin. also during your stay, you developed a slow heart rate which resolved spontaneously. finally, the infection in your heart is causing one of the valves to fail. this is causing fluid to back up into your lungs. therefore, we are trying to treat this fluid with a water pill called lasix. we have made the following medication changes: - stop ampicillin - stop enoxaparin - increase furosemide to 40mg iv daily - stop risperidone - increase prn oxycodone from 2.5mg po every 6 hours to 5-10 mg po every 4 hours - start vancomycin 1500mg iv every 48 hours, continue vancomycin until for 6 week course of endocarditis (start date ). - start senna/bisacodyl prn - start colace twice daily - start hydralazine 20 mg po/ng q6h - start isosorbide 60 mg po daily - start guaifenasen prn cough - start trazodone 25mg po daily as needed for insomnia - start metoprolol tartrate 6.25mg twice daily - start lorazepam 0.5 mg po qhs followup instructions: department: hematology/oncology when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: cardiac services when: thursday at 3:00 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage md, procedure: injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified mitral valve disorders congestive heart failure, unspecified unspecified essential hypertension chronic hepatitis c without mention of hepatic coma acute kidney failure, unspecified obstructive chronic bronchitis with (acute) exacerbation acute on chronic diastolic heart failure bacteremia malignant neoplasm of other parts of bronchus or lung acute and subacute bacterial endocarditis hypoxemia staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria other specified transient mental disorders due to conditions classified elsewhere, other 

Answer: The patient is high likely exposed to