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: urinary retention major surgical or invasive procedure: peg tube placement intubation and extubation picc line and replaced over wire history of present illness: mr. is an 82-year-old right-handed man with history of dm and prior aortic aneurysm who was admitted to the neurology service after a syncopal episode in neurology clinic . he was underoing evaluation for gait instability and was to undergo a large volume lp for possible nph. multiple attempts were made without success and had sudden severe pain down his entire right leg then became pale, clammy and diaphoretic with an unmeasurable blood pressure and thready pulse. at this time his legs were numb and he was unable to move them. a code blue was called and bp improved from 62/palp with a fluid bolus, and then transferred to the ed. there he could move his legs but had some numbness on his medial right thigh. he was unable to void and a foley catheter was placed. he was admitted to the neurology service and an mri of the lumbar spine showed a scoliotic lumbar spine with small fluid level at termination of thecal sac suggestive of small hemorrhage as well as thecal sac narrowing at l3/4. last evening after foley removal he was still unable to void and bladder scan showed 650 cc. he was recommended to stay for further management but insisted on being discharged home last evening. today he was still unable to urinate. he can feel the urge to urinate but nothing will come out, and had suprapubic pain. he had a normal bowel movement this am and no saddle anesthesia. his lower back pain is worse and he reports worsened leg pain and weakness compared to yesterday, requiring a walker to ambulate which is unusual for him. he went to good samaratian ed where they placed a foley and transferred him here for further evaluation and management. no recent fevers, chills, cough, sob, vomiting, or diarrhea. at baseline (for past month or so) he has had some difficulty initiating urination but has always been able to empty his bladder completely in the past and no history of incontinence. past medical history: - dm - s/p aortic aneurysm repair - pad (on cilostazole) - ?bph (has seen a urologist in ; not medicated) social history: lives in with his son, works as an accountant. has smoked ~1ppd for the past 60 years. drinks social alcohol (~1/month). no illicits. family history: mother died at 70 of stomach cancer. father died at 43 of renal cancer and etoh abuse. physical exam: < on admission > vs; t 96.9 p 72 bp 170/98 rr 16 96% ra gen; lying in bed, nad heent; nc/at cv; rrr, no murmurs pulm; cta b/l abd; soft, + suprapubic tenderness to light palpation extr; no edema. foley in place. neuro; ms; a&ox3. able to relate history without difficulty. language fluent, no paraphasic errors. speech was not dysarthric. follows commands. cn; perrl 3mm-->2mm, eomi with 5-6 beats bilateral endgaze nystagmus. face sensation intact v1-v3. face symmetric. hearing intact to finger-rub b/l. palate symmetric. scm and trap strong and symmetric. tongue midline. motor; normal bulk and tone. no pronator drift, tremor, or asterixis. strength was (l/r) delt 5-/4+, bicep 5-/5-, tricep 5-/4+, wre , fe 5-/5-, ff . strength in legs appeared limited due to pain as he would grimace to light touch or resistance on most attempts, but appeared; ip +, ham 4-/4, quad 5-/5, ta 4+/5-, gastrocs (limited by pain), +. sensory; allodynia to light touch in soles of feet and lower legs. hyperalgesia to pinprick in left shin and buttock. decreased vibration at toes. no saddle anesthesia. reflexes; 3 and symmetric ant r and l bicep, tricep, brachioradialis, and patellars, 2 at achilles. patient requested to defer plantar response allodynia. coordination; no dysmetria on fnf b/l. gait; deferred <on discharge: > physical exam: gen: drowsy, but easily aroused, answer questions with 1-word answers heent: mm mildly dry, op clear, stiff neck with meningismus cv: irregularly irregular hs normal pulm: crackles at l-base heard laterally abd: soft, nt, nd, peg-tube in place with c/d/i dressing. ext: no peripheral edema . neurological exam: - mental status: fluctuates and worse in am. pt at times aware he is in , knows it was , but unsure of the date and thought it was . able to follow simple midline, appendicular and crossbody commands. - cranial nerves: perrl 3->2mm, eomi, tongue midline, shoulder shrug 4+/5 bilat. - motor: increased tone in le's bilat, decreased bulk in le's bilaterally, effort dependent strength in ues bilaterally, with deltoids weakest, but lue is stronger than rue. able to move lue off bed into air, and able to move rle, but not off bed. intermittent cooperation. - coordination: fnf intact if done near pt's lap, but unable to lift up deltoid to do fnf at nose-level. pertinent results: admission labs: 07:55am blood wbc-10.5 rbc-4.44* hgb-15.6 hct-44.7 mcv-101* mch-35.2* mchc-35.0 rdw-14.2 plt ct-183 10:40am blood wbc-8.9 rbc-3.94* hgb-13.9* hct-38.9* mcv-99* mch-35.4* mchc-35.8* rdw-14.3 plt ct-166 07:30am blood wbc-7.6 rbc-3.77* hgb-13.7* hct-37.8* mcv-100* mch-36.4* mchc-36.3* rdw-13.8 plt ct-173 07:45am blood wbc-7.7 rbc-3.88* hgb-14.0 hct-39.1* mcv-101* mch-36.0* mchc-35.8* rdw-13.7 plt ct-183 12:15am blood wbc-7.1 rbc-3.82* hgb-14.0 hct-38.2* mcv-100* mch-36.6* mchc-36.6* rdw-13.7 plt ct-172 10:40am blood neuts-82.7* lymphs-11.5* monos-4.5 eos-0.8 baso-0.6 12:15am blood neuts-68.0 lymphs-22.3 monos-6.0 eos-2.4 baso-1.2 10:40am blood pt-11.9 ptt-24.8 inr(pt)-1.0 07:45am blood pt-11.7 ptt-23.0 inr(pt)-1.0 01:55am blood pt-12.3 ptt-24.1 inr(pt)-1.0 07:55am blood glucose-154* urean-18 creat-0.9 na-133 k-4.2 cl-97 hco3-19* angap-21* 10:40am blood glucose-163* urean-18 creat-1.1 na-135 k-3.9 cl-98 hco3-23 angap-18 07:30am blood glucose-151* urean-19 creat-1.0 na-136 k-3.8 cl-102 hco3-19* angap-19 07:45am blood glucose-166* urean-20 creat-1.0 na-135 k-4.1 cl-100 hco3-20* angap-19 12:15am blood glucose-125* urean-17 creat-1.0 na-139 k-3.3 cl-102 hco3-23 angap-17 07:55am blood alt-20 ast-55* alkphos-100 totbili-0.8 10:40am blood alt-21 ast-53* ck(cpk)-114 alkphos-93 totbili-0.6 12:15am blood alt-18 ast-63* alkphos-92 totbili-0.5 10:40am blood lipase-31 07:55am blood ck-mb-3 ctropnt-<0.01 10:40am blood ck-mb-3 ctropnt-0.02* 07:55am blood albumin-4.4 calcium-9.9 phos-2.8 mg-2.0 10:40am blood albumin-4.3 calcium-9.5 phos-2.8 mg-1.9 07:30am blood calcium-9.3 phos-2.4* mg-1.9 07:45am blood calcium-9.3 phos-2.6* mg-1.9 12:15am blood calcium-9.3 mg-2.0 12:15am blood vitb12-873 08:15pm urine color-yellow appear-hazy sp -1.016 08:15pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-10 bilirub-neg urobiln-2* ph-7.0 leuks-tr 08:15pm urine rbc-2 wbc-5 bacteri-few yeast-none epi-<1 08:15pm urine mucous-rare 08:15pm urine amorphx-occ . other pertinent labs: 03:24am blood fibrino-501* 07:16pm blood esr-4 07:16pm blood esr-4 03:24am blood ret aut-1.3 05:03am blood alt-21 ast-38 ld(ldh)-270* alkphos-96 amylase-99 totbili-0.4 05:02am blood alt-57* ast-67* ld(ldh)-190 alkphos-184* amylase-117* totbili-0.3 05:25am blood alt-81* ast-101* ld(ldh)-221 alkphos-178* amylase-113* totbili-0.4 10:11am blood alt-68* ast-75* ld(ldh)-216 alkphos-189* amylase-98 totbili-0.4 05:50am blood alt-53* ast-54* ld(ldh)-184 alkphos-174* amylase-91 totbili-0.3 10:40am blood lipase-31 05:03am blood lipase-72* 02:11am blood lipase-137* 01:45am blood lipase-125* 05:02am blood lipase-75* 05:25am blood lipase-49 10:11am blood lipase-51 05:50am blood lipase-41 10:40am blood ck-mb-3 ctropnt-0.02* 07:55am blood ck-mb-3 ctropnt-<0.01 08:00am blood ck-mb-3 ctropnt-<0.01 07:16pm blood ck-mb-4 ctropnt-<0.01 01:22pm blood ck-mb-3 ctropnt-<0.01 05:25am blood albumin-3.2* calcium-8.9 phos-2.9 mg-2.0 10:11am blood albumin-3.1* calcium-8.6 phos-3.0 mg-2.0 03:24am blood caltibc-172* hapto-325* ferritn-680* trf-132* 05:20pm blood folate-greater th 12:15am blood vitb12-873 07:16pm blood triglyc-88 12:30pm blood ammonia-10 10:11am blood ammonia-14 06:20am blood tsh-2.9 06:20am blood t3-68* 05:03am blood crp-13.3* 08:45pm blood lactate-2.4* 03:54pm blood lactate-2.3* 12:26am blood lactate-1.7 05:09am blood lactate-1.6 03:18pm blood lactate-1.2 . discharge labs: 06:50am blood wbc-6.4 rbc-2.80* hgb-9.8* hct-28.2* mcv-100* mch-34.9* mchc-34.7 rdw-16.5* plt ct-261 06:50am blood glucose-187* urean-18 creat-0.5 na-139 k-3.6 cl-103 hco3-28 angap-12 06:50am blood alt-43* ast-62* ld(ldh)-216 alkphos-132* totbili-0.3 06:50am blood calcium-9.0 phos-2.9 mg-2.1 . . urine: 08:15pm urine color-yellow appear-hazy sp -1.016 12:26pm urine color-yellow appear-clear sp -1.024 04:36am urine color-straw appear-clear sp -1.040* 10:50am urine color-straw appear-clear sp -1.015 11:07am urine color-yellow appear-clear sp -1.018 08:15pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-10 bilirub-neg urobiln-2* ph-7.0 leuks-tr 12:26pm urine blood-tr nitrite-neg protein-30 glucose-100 ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 04:36am urine blood-mod nitrite-neg protein-100 glucose-300 ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 10:50am urine blood-mod nitrite-neg protein-30 glucose-tr ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 11:07am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 08:15pm urine rbc-2 wbc-5 bacteri-few yeast-none epi-<1 12:26pm urine rbc-2 wbc-3 bacteri-few yeast-none epi-0 04:36am urine rbc-5* wbc-1 bacteri-none yeast-none epi-0 10:50am urine rbc-1 wbc-1 bacteri-none yeast-none epi-0 11:07am urine rbc-10* wbc-1 bacteri-few yeast-none epi-0 transe-<1 12:26pm urine casthy-4* 11:07am urine casthy-1* 08:15pm urine amorphx-occ 12:26pm urine caoxalx-few 08:15pm urine mucous-rare 12:26pm urine mucous-rare 04:36am urine mucous-rare 10:50am urine mucous-rare 11:07am urine mucous-rare 12:26pm urine hours-random creat-104 na-49 k-49 cl-75 . . microbiology blood culture blood culture, routine-pending at time of writing blood culture blood culture, routine-pending at time of writing urine urine culture-no growth stool clostridium difficile toxin a & b test-negative urine urine culture-no growth stool clostridium difficile toxin a & b test-final inpatient sputum gram stain-final; respiratory culture contaminated blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth 10:50 am blood culture ( myco/f lytic bottle) source: line-picc line. m.furfur added on @1237. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. m. furfur blood culture (preliminary): 12:47 pm sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. yeast. sparse growth. stool clostridium difficile toxin a & b test-negative 10:36 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. yeast. sparse growth. blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth urine urine culture-no growth blood culture blood culture, routine-no growth mrsa screen mrsa screen-negative blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth urine urine culture-no growth . . radiology: radiology mr l spine w/o contrast findings: again noted is significant levoconvex scoliosis of the lumbar spine which mildly complicates evaluation. there is a large amount of layering fluid within the subarachnoid space that is t1 hyper-, t2 and stir hypointense. this has dramatically increased in amount compared to the mri from and causes rightward displacement of the conus medullaris and the nerve roots of the cauda equina. there is heterogeneous appearance of the bone marrow of the visible vertebral bodies. no loss of intervertebral body height is noted. there is fusion of the l5 and l4 vertebral bodies. otherwise, the intervertebral disc spaces are normal in signal intensity and morphology. no epidural hematoma is noted. at t12-l1, no significant degenerative disc disease or degenerative joint disease is noted. no neural foraminal narrowing is present. at l1-l2, no significant neural foraminal narrowing is present. at l2-l3, no significant neural foraminal narrowing, disc bulge, or facet joint hypertrophy is noted. at l3-l4, there is mild spinal canal narrowing related to ligamentum flavum hypertrophy and a mild posterior disc bulge as well as bilateral facet joint hypertrophy, although no significant neural foraminal narrowing is present. the l4-l5 disc is absent due to spinal fusion. at l5-s1, there is mild facet joint hypertrophy causing minimal bilateral neural foraminal narrowing, but no significant spinal canal stenosis is present. the partially imaged abdomen is unremarkable and better evaluated on the concurrently performed ct. a repaired aortic aneurysm is partially imaged. impression: dramatic interval progression of a subarachnoid and possibly subdural hemorrhage with acute as well as chronic blood components noted. . radiology abdomen (supine & erect indication: blood within the thecal sac status post attempted lumbar puncture, now with abdominal pain on exam. evaluate for intra-abdominal pathology. comparison: ct abdomen/pelvis from . findings: there is gaseous dilation of both the small and large bowel. no definite free air is seen in the abdomen. a large volume of stool is seen in the cecum. there is marked levoscoliosis of the lumbar spine centered at l3. elevation of the left hemidiaphragm is noted. impression: 1. multiple dilated air-filled loops of small bowel and colon are most consistent with ileus or air-swallowing. 2. no evidence of free air in the abdomen. . radiology ct abd & pelvis with co liver: the liver is small in size and slightly nodular with no focal mass. no evidence of fatty infiltration. there is no bile duct dilatation. the gallbladder is unremarkable. pancreas: the pancreas is atrophic with no focal mass or diffuse abnormality. there is no peripancreatic stranding. spleen: the spleen is normal in size and homogeneous. kidneys: the left kidney is normal in size with no focal solid or cystic mass. it excretes contrast in normal fashion. the rightkidney shows anterior cortical scarring and is smaller than the left, likely due to vascular insult. the right kidney excretes contrast in a normal fashion. there is no hydronephrosis bilaterally. the proximal ureters appear normal. adrenals: the right adrenal gland is normal.there is a 5-mm bulge/nodule at the body of the left adrenal gland as previously. bowel: the small bowel is not dilated and there is appropriate transit of the oral contrast through it. the cecum, ascending colon as well as the transverse colon are dilated. the maximum diameter is 9.5 cm at the cecum. there is gradual tapering of the distal colon without focal obstructing lesion. there is no evidence of small-bowel obstruction. abdomen: there is no ascites or other fluid collections seen in the peritoneum, mesentery, or retroperitoneum. vascular: status post aortobi-iliac graft, which is patent. there is occlusion of the right superdicial femoral artery, unchanged since the previous study of . ct of the pelvis there is nof free fluid. fecal material seen in the rectum. no mass. enlarged prostate is noted. skeletal: there are no blastic or lytic lesions. degenerative changes in the lumbar spine noted. impression: nonspecific dilatation of the colon. no evidence of small-bowel obstruction. . kub :impression: persistent ileus. . kub7/5/11:impression: persistent ileus, unchanged compared with , and . . mri spine : impression: 1. overall, minimal change with redemonstration of extensive intrathecal and subdural hemorrhage in the lumbar spine and thoracic spine as above. . cxr :impression: ap chest compared to : lungs are substantially lower in volume so that opacification of the lung bases medially is more likely atelectasis than pneumonia. upper lungs are clear. heart size is difficult to assess since heart border is obscured by the elevated diaphragm. no pneumothorax or pleural effusion. right central venous line ends low in the svc. nasogastric tube ends in the distal stomach. . ct abdomen/pelvis : impression: 1. no evidence of bowel ischemia or enteritis/colitis. 2. chronic pulmonary parenchymal changes are stable. 3. stable appearance of aortobifemoral bypass graft which remains patent, with chronic occlusion of the right superficial femoral artery. . cxr : impression: ap chest compared to : lung volumes have improved. heart size is normal. thoracic aorta is generally large but not focally aneurysmal. there is no pleural abnormality or evidence of central adenopathy. a right-sided central venous line ends in the upper svc and a nasogastric tube ends in the upper stomach. no pneumothorax. . head ct :impression: 1. bilateral tiny hemorrhages layering dependently in the occipital lobes of lateral ventricles 2. the basilar artery appears dense and correlation with possible neurological symptoms must be made. if clinical symptoms are present, mri is the recommended study of choice for further evaluation. . mri : impression: 1. tiny area of diffusion abnormality is seen in the left periventricular region is not visualized on the adc map and could be due to t2 shine-through, but a small acute infarct could not be excluded given its small size and which could not be appreciated on the adc map. no large territorial infarct is seen. 2. ventriculomegaly and prominence of sulci, which in presence of prominent sulci and fissures and absence of hyperdynamic flow through the aqueduct is likely secondary to global atrophy. 3. no evidence of abnormal enhancement within the brain. 4. no evidence of chronic microhemorrhages. . chest (portable ap) study date of 2:57 am mild pulmonary edema has improved. worsening heterogeneous opacification at the base of the left lung could be atelectasis alone, or aspiration. suggest followup to exclude development of pneumonia. heart size is normal. mediastinal vascular engorgement, persists. heart size is normal. et tube in standard placement. right central venous line ends in the upper svc and a nasogastric tube ends in the distal stomach. no pneumothorax. . portable abdomen study date of 3:28 am impression: dilatation of bowel consistent with ileus . mri brain mra head/neck w&w/o contrast study date of 9:43 pm findings: mri brain: there is a small focus of altered signal intensity involving the body of caudate nucleus and corona radiata. left ventricular location shows diffusion restriction and low adc values consistent with an acute infarct. there is moderate-to-severe ventriculomegaly with dilatation of bilateral lateral third and fourth ventricles. ventricular dilatation appears out of proportion to the prominence of sulci. there is increased periventricular t2 and flair signal intensity which is likely secondary to chronic microvascular ischemic disease. there are no foci of parenchymal susceptibility seen. following gadolinium administration, there is no evidence of abnormal parenchymal enhancement. mra neck: high grade stenosis is seen at the origin of left internal carotid artery with complete loss of signal. however, there is immediate reconstitution distal to the stenotic segment. given the signal loss, the extent of stenosis is estimated to be more than 60%; however, it is expected to be less than 90% since the vessel is getting immediately reconstituted. the right carotid and bilateral vertebral arteries show normal flow signal without stenosis or occlusion. mra head: diffuse atheromatous changes are seen in the arteries of anterior and posterior circulation. there is no significant stenosis or occlusion or aneurysm identified. impression: 1. acute lacunar infarct involving body of caudate nucleus and corona radiata in left periventricular location. 2. high-grade stenosis at the origin of left internal carotid artery. 3. unchanged moderate communicating hydrocephalus and chronic microvascular ischemic disease. . abdomen u.s. (complete study) study date of 12:52 pm impression: 1. no gallstones or signs of cholecystitis identified. no biliary dilatation. 2. atrophic right kidney, which demonstrates cortical thinning. this could suggest the presence of a renal artery stenosis or other chronic renal disease. 3. atherosclerotic aorta with no aaa. . chest (portable ap) study date of 9:04 pm despite low lung volumes, patient has emphysema with mild bibasilar fibrosis. on today's examination, there is a relative increase in mediastinal vascular caliber, so that slight increase in bibasilar opacification could be due to early edema. heart is normal size. there is no pneumothorax. nasogastric tube passes to the region of the pylorus. right pic line has been partially withdrawn, roughly to the level of the origin of the right brachiocephalic vein at the thoracic inlet. . mr head w & w/o contrast study date of 12:10 am impression: 1.unchanged moderate communicating hydrocephalus with minimal intraventricular bleed and chronic microvascular ischemic disease. interval evolution of acute lacunar involving the body of left caudate nucleus as seen on the prior scan. 2. superficial siderosis in infratentorial compartment as described, likely secondary to prior subarachnoid hemorrhage. . chest (portable ap) study date of 11:06 am the orogastric tube is coursing below the diaphragm and the distal end is seen coiled within the body of stomach. the right picc line is terminating in the right subclavian vein, probably just proximal to the origin of the brachiocephalic trunk and the position is unchanged since , . lung volumes remain low. bilateral interstitial opacities in the lung bases have remained stable, attributed to the known coexisting copd and interstitial lung disease. there is a new discrete opacity in the left lower lung, which is concerning for focus of pneumonic consolidation and needs attention on further followup imaging. cardiomediastinal shadow is normal. . . neurophysiology: eeg : impression: this is an abnormal continuous icu monitoring study because of moderate to severe diffuse background slowing, discontinuity, and disorganization, with nearly continuous right hemisphere periodic lateralized epileptiform discharges (pleds). these epileptiform discharges over the right hemisphere showed rhythmic buildup during periods of arousal, but did not evolve into clear electrographic seizures. these findings are indicative of highly potentially epileptogenic focal dysfunction in the right parietal region. over the course of the recording, the epochs with right hemisphere pleds became less frequent. there are independent epileptiform discharges over the left hemisphere, indicating an additional epileptogenic focus in this region. moderate to severe diffuse background slowing is indicative of moderate to severe diffuse cerebral dysfunction, which is etiologically nonspecific. compared to the prior days recording, there is no significant change. . eeg : impression: this is an abnormal continuous icu monitoring study because of moderate to severe diffuse background slowing, discontinuity, and disorganization, with nearly continuous right hemisphere periodic lateralized epileptiform discharges (pleds). these epileptiform discharges over the right hemisphere showed rhythmic buildup during periods of arousal, but did not evolve into clear electrographic seizures. these findings are indicative of highly potentially epileptogenic focal dysfunction in the right parietal region. there are independent epileptiform discharges over the left hemisphere, indicating an additional epileptogenic focus in this region. moderate to severe diffuse background slowing is indicative of moderate to severe diffuse cerebral dysfunction, which is etiologically nonspecific. compared to the prior days recording, there is no significant change. . eeg : impression: this is an abnormal continuous icu monitoring study because of moderate to severe diffuse background slowing, discontinuity, and disorganization, with epochs of right hemisphere periodic lateralized epileptiform discharges (pleds). these epileptiform discharges over the right hemisphere showed rhythmic buildup during periods of arousal, but did not evolve into clear electrographic seizures. these findings are indicative of highly potentially epileptogenic focal dysfunction in the right parietal region. there are independent epileptiform discharges over the left hemisphere, indicating an additional epileptogenic focus in this region. moderate to severe diffuse background slowing is indicative of moderate to severe diffuse cerebral dysfunction, which is etiologically nonspecific. compared to the prior days recording, the periodic discharges are less frequent and occur with a lower repetition rate. there was one clinical episode of myoclonic jerking of the patient's head and shoulders, but this did not show a clear eeg correlate. . eeg study date of impression: this is an abnormal continuous icu monitoring study because of moderate to severe diffuse background slowing, discontinuity, and disorganization, with epochs of right hemisphere periodic lateralized epileptiform discharges (pleds). these epileptiform discharges over the right hemisphere showed rhythmic buildup during periods of arousal, but did not evolve into clear electrographic seizures. these findings are indicative of highly potentially epileptogenic focal dysfunction in the right parietal region. there are independent epileptiform discharges over the left hemisphere, indicating an additional epileptogenic focus in this region. moderate to severe diffuse background slowing is indicative of moderate to severe diffuse cerebral dysfunction, which is etiologically nonspecific. compared to the prior days recording, periodic epileptiform discharges are less frequent and appear less epileptiform. . eeg study date of impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing disorganization with continuous focal slowing over the right hemisphere and right hemisphere sharp waves. the epileptiform discharges are much less prominent and have less epileptiform morphology. these findings are indicative of potentially epileptogenic focal dysfunction in the right parietal region. moderate diffuse background slowing is indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. compared to the prior day's recording, there is no significant change. there are no electrographic seizures. . eeg study date of impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing disorganization, with continuous focal slowing over the right hemisphere and right hemisphere sharp waves. the epileptiform discharges are much less prominent and have less epileptiform morphology. these findings are indicative of potentially epileptogenic focal dysfunction in the right parietal region. moderate diffuse background slowing is indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. compared to the prior days recording, right hemisphere sharp waves are less frequent, and the background frequencies have improved bilaterally. there is recurrence of the previously-seen left central sharp waves. there are no electrographic seizures. . . cardiology: tte (complete) done at 9:16:22 am conclusions the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . ecg study date of 8:55:24 am sinus rhythm. occasional atrial premature beats. prominent early r wave transition. compared to the previous tracing of occasional premature atrial contractions are new. read by: , intervals axes rate pr qrs qt/qtc p qrs t 68 144 80 374/388 45 28 66 brief hospital course: primary diagnoses 1. subarachnoid spinal hemorrhage s/p attempted lumbar puncture 2. urinary retention 3. aspiration pneumonia 4. left lacunar infarct secondary diagnoses 1. diabetes mellitus 2. peripheral vascular disease . . 82-year-old right-handed man with history of dm and prior aortic aneurysm who was admitted to the neurology service after a syncopal episode in neurology clinic . he was underoing evaluation for gait instability and was to undergo a large volume lp for possible nph, but became pale, clammy, and hypotensive with transient leg weakness and had difficulty with urinary retention since. mr. was re-admitted after he insisted on leaving the hospital a few days prior to re-admission, with 800ml urinary retention. he returned with persistent retention and worsened leg and back pain, also with headaches and abdominal pain. a new mr revealed substantially increased hemorrhage in his spinal canal (subarachnoid/subdural), which was thought to be the cause of his grossly increased lbp and leg pain and left-foot hyperesthesia and meningeal signs (i.e. meningeal and root and cord irritation by the blood/breakdown products). his aspirin and cilostazole were stopped at that point. pain control was achieved with iv morphine, then po tramadol and oxycodone with scheduled acetaminophen. unfortunately, on this regimen he developed a large ileus which was treated with methyl-naltrexone atop a mild bowel regimen. unfortunately, while his ileus was being treated, he developed altered mental status, and require an icu transfer. the cause of his mental status was initially unclear, but repeat mri scans showed a small l lacunar infarct and likely seizure activity related to it. he was treated with keppra and improved to the point he was able to be sent to rehab on . . # neuro: patient continued to have meningeal signs throughout his stay. he received a dose of 40mg prednisone on to help with his meningeal signs, but then refused his dose and . his mental status worsened on the morning/early afternoon of . he also got his prednisone dose through an ngt, which may have precipitated his mental status change on , as he likely had an infection brewing given his elevated wbc (prior to prednisone). on his mental status further deteriorated and he was no longer responsive to voice. he got a repeat mri spine which showed stable blood in his csf. he got a head ct which showed tiny hemorrhages layering dependently in the occipital lobes of lateral ventricles and a basilar artery density which may represent dehydration vs stroke. his eeg which had been placed earlier in the day showed some r temporal pleds. he then got a cta and mri which showed a question of small stroke, which on repeat mri was confirmed as a small l lacune. his mental status further deteriorated and he was sent to the micu for better monitoring. there, he was noted to have seizure-like activity, for which he was treated with keppra. he was also intubated to protect his airway. he recovered, and was able to be sent out of the icu, where his mental status was still depressed. his lfts began to increase, and so his tylenol was held. soon thereafter patient's mental status improved. he has a speech and swallow eval that showed profound aspiration and his ngt was removed and a peg was placed. his cxr showed a possible lll pna, and he was started on vanc and ceftriaxone and his mental status further improved to the point where he was able to be sent to rehab. abx course to finish on . patient has neurology follow-up on . . # respiratory failure: micu was called when the patient became tachypneic to 40s and tachycardic to 130s. he received 5mg iv metoprolol with drop of hr to low 100s and lasix 20mg iv for suspected flash pulmonary edema. patient was intubated for airway protection given altered mental status. he was extubated once ms improved. treated with iv antibiotics for recurrent aspiration pneumonia. now s/p peg. . # id: patient's wbc elevated on evening of elevated from 10->17 (prior to getting prednisone done). presumably pt was brewing an infection that caused this elevation, but we were not sure where the infection was. the patient had an mri spine that did not show a source of infection, and the patient had a ct abdomen that also did not show a source of infection. pt's u/a was not infected. patient's lung exam did worsen from to and therefore we suspected a lung pathology. we started pt on ceftriaxone and vancomycin on night of and azithromycin on . in micu patient was treated with broad specturm antibiotics for presumed infection and covered emperically for meningitis per neuro. he completed a 14 day course of vanc and ceftriaxone, but when his cxr showed a new lll pna he was restarted on an 8 day course of vanc and ceftriaxone to finish on . new picc was placed over a wire (had been pulled out previously necessitating this) on and ok to use. . # gi: pt began complaining of abdominal pain on when he was readmitted. on imaging he developed an ileus sometime between and . he began to complain of worsening abdominal pain around , but his abdomen remained soft with some ttp in ruq and rlq. he received methylnaltrexone x1, enemas and an aggressive bowel regimen, but his ileus remained stable and possibly worsened from to . gi was consulted to assist with management of his abdominal pain and ileus. they recommended a ct abdomen which showed persistent ileus but acute issue. also they recommended consulting surgery for possible mesenteric ischemia, but surgery found no evidence of mesenteric ichemia on ct. his bowel regimen was held and the patient was restarted on tube feeds after extubation. cdiff was negative x3. his ileus improved and he was able to pass stool on a regular basis. please note that this patient should not be given standing or frequent tylenol, as his liver function is very easily effected by tylenol and likely causes a mental status decompensation. . # gu: pt will need outpatient urology follow-up for his urinary retention; although this is likely in part neurogenic, he has a history of bph untreated and ltfu. we inserted a foley catheter and started flomax. plan on discharge was to continue foley catheter until outpatient urodynamic study. pt is to continue taking flomax (started here). . # cards: on pt was put on telemetry with his eeg and was shown to be in (presumably new) afib with rvr, which was then slowed with iv lopressor. he remained in atrial fibrillation throughout the admission. the decision was made to start the patient on aspirin, but not heparin because of the risk of bleeding into the epidural space. . . pending labs: bcx x2 from transitional care issues: patient on iv antibiotics for aspiratiion pneumonia and will complete further 8 day course on . we will need to ensure that pt's urinary retention resolves or he has appropriate management. he has a urology follow-up appointment already made. medications on admission: -aspirin 81 mg daily -lasix 10 mg daily -metformin 1000 mg -cilostazole 50 mg daily discharge medications: 1. tamsulosin 0.4 mg capsule, ext release 24 hr : one (1) capsule, ext release 24 hr po hs (at bedtime) as needed for bph, retention: new medication for bph. 2. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day). 3. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 4. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 5. insulin regular human 100 unit/ml solution : sliding scale injection asdir (as directed). 6. lactulose 10 gram/15 ml solution : 1000 (1000) mls po bid (2 times a day) as needed for constipation. 7. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily) as needed for back pain: patch should be on for 12hrs and off for 12hrs in a given 24hr period. 9. aspirin 325 mg tablet : one (1) tablet po daily (daily). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for sob, wheeze, cough. 11. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours). 12. gabapentin 300 mg capsule : one (1) capsule po q8h (every 8 hours). 13. cilostazol 50 mg tablet : one (1) tablet po daily (daily). 14. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed for rash. 15. levetiracetam 100 mg/ml solution : five hundred (500) mg po bid (2 times a day). 16. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 17. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback : one (1) gram intravenous q24h (every 24 hours): last dose to be to complete an 8 day course. 18. vancomycin 500 mg recon soln : seven y (750) mg intravenous q 12h (every 12 hours): to complete 8 day course. last day . discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses 1. subarachnoid spinal hemorrhage s/p attempted lumbar puncture 2. urinary retention 3. aspiration pneumonia 4. left lacunar infarct secondary diagnoses 1. diabetes mellitus 2. peripheral vascular disease discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. neuro exam: responsive to simple commands, able to say 1-word answer ('hospital', 'yes'), withdraws to painful stimuli on , and is able to move and withdraws to painful stim on ues bilat and can have purposeful movement with his ues bilaterally. discharge instructions: dear mr. , you were re-admitted to our hospital after your recent stay due to persistent urinary retention and worsened leg and back pain, with headaches and abdominal pain. you were found to have increased hemorrhage inside your spinal canal, which was causing pain and irritation of your spinal nerves and spinal cord. we stopped your aspirin and cilostazol, which can increase the bleeding. we gave you pain medicines to help with the pain while the blood is resorbed. some of the pain medicines made you constipated, and we gave you medicines to help with the resulting ileus and discomfort. you had a small stroke while you were here, which caused you to have seizures. this resulted in your being transferred to the icu for intubation and management of your altered mental status. you were then transferred back to the floor, where you continued to improve. your swallowing, however, was very impaired, and you had to have a peg placed on . because of your swallowing you developed an aspiration pneumonia, which we treated with antibiotics. you were then able to be sent to rehab to complete your course of antibiotics and to get stronger with physical therapy. we made the following changes to your medications: 1) we stopped your metformin. 2) we started you on an insulin sliding scale. your rehab facility can create and adjust this scale for you. 3) we started you on tamsulosin 0.4mg once a day. 4) we started you on senna 8.6mg twice a day as needed for constipation. 5) we started you on docusate 100mg twice a day as needed for constipation. 6) we started you on bisacodyl 10mg per rectum daily as needed for constipation. 7) we started you on a lactulose enema 1000ml twice a day as needed for constipation. 8) we started you on metoprolol 12.5mg twice a day. 9) we started you on a lidocaine 5% patch. 10) we started you on albuterol nebs, once every six hours as needed for wheezing or shortness of breath. 11) we started you on ipratropium nebs, once every 6 hours. 12) we started you on gabapentin 300mg every 8 hours. 13) we started you on miconazole powder 1 application four times a day as needed for rash. 14) we started you on keppra 500mg twice a day. 15) we started you on lansoprazole 30mg once a day. 16) we started you on ceftriaxone 1gm q24h, with last dose . 17) we started you on vancomycin 1gm q24h with last dose . 18) we stopped your lasix. 19) we increased your aspirin to 325mg once a day. please continue to take your other medications as previously prescribed. if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospitalization. followup instructions: department: surgical specialties when: thursday at 3:30 pm with: pelvic floor unit building: sc clinical ctr campus: east best parking: garage department: neurology when: monday at 4:30 pm with: drs. & building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] diagnoses: anemia, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia hematoma complicating a procedure acute respiratory failure pneumonitis due to inhalation of food or vomitus paralytic ileus retention of urine, unspecified encephalopathy, unspecified cerebral artery occlusion, unspecified with cerebral infarction dysphagia, unspecified cauda equina syndrome without mention of neurogenic bladder idiopathic normal pressure hydrocephalus (inph) 

Answer: The patient is high likely exposed to