Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: penicillins / sulfa (sulfonamide antibiotics) attending: chief complaint: nausea, vomiting, dysuria major surgical or invasive procedure: incision and drainage of perinephric mass : resection of medial of right clavicle. resection of sternoclavicular joint. partial resection of sternum and costochondral junction of the 1st rib. 1. surgical preparation of chest wound 12 x 12 cm. 2. pectoralis myofascial flap. 3. local tissue advancement and rearrangement of skin for closure of chest defect 12 x 12 cm. right thoracentesis with chest tube placement and subsequent removal history of present illness: this is a 50 year old female with pmh of asthma, questionable tia vs. complex migraine 2 months ago, poorly controlled dm1 with last a1c of 13 and htn c/b esrd s/p living related donor renal transplant in presenting with 4 days of dysuria and 2 days of nausea and non-bloody, non-bilious emesis. she was seen today at her pcp's office and referred to the ed after being found to be orthostatic with a bp of 118/62 lying, 82/36 sitting, and 70/40 standing. she has had no urinary frequency or hematuria and was noted to be extremely anxious about potential renal failure. of note, she was also seen last week for fever to 102, cough, and diarrhea and prescribed azithromycin with resolution of her symptoms. she currently denies any f, abd pain, diarrhea, constipation, or cough. she has been having some chest burning likely related to esophageal irritation from frequent vomiting. she has also been having some right shoulder pain which she attributes to an injury she had from grabbing the toilet in an episode of violent vomiting. she has also noted dyspnea on exertion and chills as of late. . in ed, vitals were 98.2 82 129/58 16 97% ra. per her pcp's exam, she was noted to have some difficulty standing for orthostatics and mild epigastric tenderness. she was also noted to have right shoulder pain worse with movement, coughing, and lifting. on ed exam her graft was not ttp. per the , ekg did not show any changes from prior. a cxr was also performed and did not show any acute cardiopulmonary abnormality per the ed. a renal transplant ultrasound was performed but not reviewed in the ed. labs were significant for a wbc count of 25.4, thrombocytosis to 980, floridly positive ua, hyponatremia to 127, creatinine of 2.5, and an anion gap of 15. she was given maalox/simethicone/lidocaine which did not help her chest burning and she reported vomiting it up, morphine 4mg iv for right shoulder pain, cipro 400mg iv, and 2l of ns. blood cultures were performed, but urine culture was not sent. she was admitted for uti and acute renal failure. most recent vitals: 97.8 108 124/56 18 100ra. . review of sytems: (+) per hpi (-) denies fever, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest tightness, palpitations. denied diarrhea, constipation. past medical history: -hypertension -type 1 diabetes since , poorly controlled with last a1c of 13 -asthma -esrd s/p living-related renal transplant in -tia vs. complex migraine in , started on plavix thereafter social history: she lives with her mother at home and is her mother's primary caretaker. brother has flown in from to care for her while she is hospitalized. she does not have any children but reports good social support from friends and -workers. she works for the massport website full-time. she does not smoke or drink etoh. family history: father had als but otherwise not significant. physical exam: admission: vs - temp=99.2, bp=102/60, hr=110, r=20, o2-sat 99% ra general - well-appearing female in nad, comfortable, appropriate, with intermittent chills noted heent - nc/at, perrla, eomi, sclerae anicteric, dry mm, op clear neck - supple, no jvd. lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - tachycardic, 2/6 sem noted abdomen - nabs, soft/nt/nd, no rebound/guarding extremities - wwp, no c/c/e. neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout. discharge: general: no longer with intermittant rigors heart: rrr, 2/6 sem at rusb lungs: rales at the bases of the posterior lung fields bilaterally extremities: 2+ pitting edema in the lower extremities bilaterally otherwise unchanged from admission pertinent results: admission labs: 02:16pm blood wbc-25.4*# rbc-4.34 hgb-11.1* hct-35.1* mcv-81*# mch-25.4* mchc-31.4 rdw-13.0 plt ct-980* 02:16pm blood neuts-92.1* lymphs-5.5* monos-1.6* eos-0.7 baso-0.2 02:16pm blood plt ct-980* 04:35am blood pt-14.2* ptt-33.9 inr(pt)-1.2* 02:16pm blood glucose-187* urean-70* creat-2.5*# na-127* k-4.6 cl-91* hco3-21* angap-20 02:16pm blood alt-13 ast-15 alkphos-108* totbili-0.3 04:22pm blood type- po2-66* pco2-29* ph-7.30* caltco2-15* base xs--10 comment-green top pertinent labs: 04:20am blood esr-24* 06:40am blood alt-14 ast-28 ld(ldh)-366* alkphos-120* totbili-0.3 04:55am blood lipase-8 04:55am blood ctropnt-<0.01 04:35am blood caltibc-139* hapto-362* trf-107* 12:50pm blood crp-194.9* 04:25am blood pep-no specifi 11:05am blood ebv pcr, quantitative, whole blood- 11:05am blood free kappa and lambda, with k/l ratio-test 04:25am blood jak2 mutation (v617f) analysis, plasma based-test 12:46pm blood ebv pcr, quantitative, whole blood- 12:50pm blood aspergillus galactomannan antigen-test 12:50pm blood b-glucan-test 05:45pm blood adenovirus pcr-test name microbiology: blood cx : neg urine cx : lactobacillus species vre swab negative urine cx :neg blood culture , : neg mycobacteria and fungal cultures 6/25: neg stool culture-neg, c. diff toxin a and b-neg, campybacterium culture-neg stool viral culture -prelim neg cmv viral load neg perinephric mass biopsy culture: pmns seen on gram stain. culture beta streptococcus group b sensitivities: mic expressed in mcg/ml _________________________________________________________ beta streptococcus group b | clindamycin----------- s erythromycin---------- s anaerobic culture (final ): no anaerobes isolated chest swab pmns on gram stain; beta strep group b on culture. fluid from chest pmns, no growth on culture peri-nephric mass fluid beta strep group b. right sternoclavicular joint first rib *** pectoralis muscle *** sternoclavicular fluid *** urine cytology: urothelial cells, histiocytes, and neutrophils.many squamous cells, anucleate squames, and bacteria consistent with vaginal contamination.note: atypical squamous cells consistent with low grade squamous intraepithelial lesion (lsil) are present. no other blood/urine cultures positive pathology: perinephric mass biopsy fragments of fibrovascular tissue and chronic inflammation. see note. note: the biopsy is mostly comprised of fibrous tissue and lymphocytes with some crush artifact. a separate discrete aggregate of plasma cells are identified. these plasma cells are small with eosinophilic cytoplasm and eccentrically located nuclei. no atypical forms are seen. by immunohistochemistry the plasma cells are positive for cd138 and bcl-2 and are polytypic by kappa and lambda staining. cd20 and cd10 are negative in the plasma cells with cd20 staining scattered b-cells. cd3 and cd5 highlight admixed t-cells. overall, the findings are non-specific. the differential diagnosis includes a reactive process (favored). since an early evolving (hyperplasia) post-transplant lymphoproliferative disorder cannot be excluded (due to sampling) a repeat excision may be warranted if clinically indicated. addendum: kappa and lambda ish reveals a mixed polytypic plasma cell population. is negative. overall features do not suggest a clonal process; no evidence of ptld seen. the above diagnosis remains unchanged. immunophenotyping three color gating is performed (light scatter vs. cd45) to optimize blast/lymphocyte yield. due to paucicellular nature of the specimen, a limited panel is performed to determine b-cell clonality. b cells are scant in nature precluding evaluation of clonality. biopsies of chest wall and perinephric mass 1. mass, right chest wall (a-b): a. skeletal muscle with chronic, patchy mildly active inflammation. b. fibroadipose tissue. c. no malignancy identified. 2. mass, peri-nephric (c): fibroadipose tissue with acute and chronic inflammation and fat necrosis consistent with abscess wall. pleural fluid cytology: negative for malignant cells. ultrasounds: renal u/s : impression: 1. abnormal intrarenal waveforms with blunted waveforms and lack of diastolic flow in the interpolar region. findings concerning for graft dysfunction. 2. a 3.7 x 3.2 x 2.8 cm hypoechoic lesion with internal vascularity in the interpolar region of the transplant kidney is concerning for a neoplasm. further assessment with mr is recommended. u/s chest wall soft tissue mass which is hypoechoic, predominantly solid, but with areas of partial liquefaction. this is avascular and most likely represents a focus of ptld as the appearance is not dissimilar from the peri-transplant masses, which were biopsied yesterday. chest u/s: conclusion: soft tissue mass which is hypoechoic, predominantly solid, but with areas of partial liquefaction. this is avascular and most likely represents a focus of ptld as the appearance is not dissimilar from the peri-transplant masses, which were biopsied yesterday. right upper extremity u/s 1. no right upper extremity dvt. 2. extensive right supraclavicular lymphadenopathy. lenis: no evidence of deep vein thrombosis in either leg. ct scans ct chest without contrast 1. chest wall abnormality could represent ptld, but extention into the thoracic cavity and associated bone destruction raises concern for infection. in an immunocompromised host, this could be due to invasive fungal organisms, actinomycosis, and tuberculosis, among others. 2. lung consolidation, pleural effusions and interlobular septal thickening are nonspecific. such findings have been associated with ptld but can also be associated with infection and hydrostatic edema. ct abdomen and pelvis impression: 1. multiloculated rim-enhancing fluid collection in the right anterior chest with internal foci of gas and minimal osseous destruction of the encased first rib, thought to represent abscess has had a minimal decrease in size. 2. bilateral pleural effusions with worsening right lower lung opacification, may represent ateletasis but underlying pneumonia cannot excluded. 3. four fluid collections identified around the transplanted kidney in the left lower quadrant. two had recent instrumentation and drainage, superior and lateral, and are decreased in size compared to recent mri. two larger collections noted medial and inferior demonstrate rim enhancement and intermediate density fluid concerning for infectious process. 4. foci of gas in the collecting system of the transplanted kidney, likely due to air reflux from bladder foley placement, less likely pyelitis. 5. hyperdensities in native kidneys, particularly in the right upper pole likely represent hemorrhagic cysts, particularly given appearance on recent mri. 6. volume overload is demonstrated by bilateral pleural effusions, pericardial effusion, anasarca, periportal edema and mild ascites. 7. linear lucency in right second rib likey due to recent surgery. please correlate with operative note when available. ct chest abdomen and pelvis: impression: 1. increased size of mild pericardial effusion with hyperenhancing pericardium. 2. right labia is enlarged with indurated subcutaneous fat without focal fluid collection. 3. decrease in size of anterior right chest wall abscess with two drains in place and minimal residual fluid. 4. increased bilateral pleural effusions and atelectasis. 5. increase in periportal and pericholecystic fluid with hyperenhancing gallbladder wall suggestive of edema versus gallbladder contraction. 6. decrease in size of collections surrounding the transplanted kidney and collection along the lateral abdominal wall measuring 3.3 and 2.0 cm respectively from 4.8 and 2.1 cm on prior examination. 7. air again seen in transplanted kidney, likely refluxing air. mri: mri abdomen and pelvis: impression: 1. transplanted kidney in left lower quadrant. at least three perirenal masses suspicious for ptld or lymphoma. the lesions are accessible by percutaneous biopsy. 2. multiple native renal cysts, some of them with hemorrhagic/proteinaceous content. 3. bilateral pleural effusions, right moderate amount, on the left small amount. shoulder mri:impression: 1. motion-degraded study. no evidence of septic arthritis. 2. nonspecific mild edema involving the infraspinatus, teres minor, and teres major. 3. abnormality adjacent to the coracoid process which is suboptimally evaluated on this motion-degraded study - recommend further evaluation with contrast-enhanced ct, as this could represent a mass or lymphadenopathy; collection of fluid is less likely given imaging characteristics. 4. large signal intensity abnormality in the peripheral aspect of the right upper lung, corresponding to known consolidation. mri/mra: impression: 1. acute infarct involving rostrum of corpus callosum. 2. multiple focal dilatations involving aca and mca branches bilaterally. 3. both the infarction and the vascular abnormalities suggest multiple septic emboli. echocardiograms echo : mpression:no endocarditis or abscess seen. moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild mitral regurgitation. moderate pulmonary artery systolic hypertension. echo : this is a limited examination to r/o endocarditis. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is an echo dense mass a probable vegetation on the p2 portion of the mitral valve. it measures 2- 3mm in size. dr present to confirm findings as well. mild (1+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. dr. was notified in person of the results on at 1245pm. echo : the left atrium is normal in size. the estimated right atrial pressure is 5-10 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). a mid-cavitary gradient (30mmhg peak) is identified. 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 masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate sized pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , the pericardial effusion and mid-cavitary gradient are now identified. serial evaluation is suggested. echo : impression: very small echodensity attached to the posterior mitral annular calcification at the level of the p2 scallop. compared to the prior study dated (images reviewed), the echodensity is smaller and less mobile and probably c/w with healing vegetation. small circumferential pericardial effusion without evidence of tamponade. echo : no effusion: the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. 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. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild mitral regurgitation with mild leaflet thickening, but no discrete vegetation. compared with the prior study (images reviewed) of , the findings are similar.clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. chest x-rays : impression: no acute cardiopulmonary abnormality. :findings: there are bilateral pleural effusions with volume loss at both bases. there is new right mid lung infiltrate. overall, the pulmonary appearance has worsened compared to the film from five days ago. :findings: largely loculated moderate dependent bilateral pleural effusions with associated atelectasis are new or substantially larger from . difference in effusion size from is likely due to depth of inspiration. improved aeration in the non-dependent lungs on the lateral decubitus views is secondary to positioning. the right upper lobe pneumonia is unchanged. no new consolidation is seen in the left lung. no pneumothorax. : impression: stable chest findings in comparison with preceding study of . recommend ct examination to evaluate alleged new anterior chest wall mass. : there are low inspiratory volumes and slightly less penetration of the film compared with . allowing for this, no significant interval change is detected. again seen are small effusions at the right and left bases, with underlying collapse and/or consolidation. there is a hazy opacity in the right mid zone, corresponding to the right lung abnormality seen abutting the anterior chest wall on the ct scan. there is upper zone redistribution, without other evidence of chf. : ap upright view of the chest: there is new moderate right-sided pneumothorax with partial collapse of the entire right lung following resection of the medial one-third of the right clavicle and first anterior rib. minimal leftward shift of the mediastinum may be related to large left lower lung atelectasis. small right effusion is present. heart size is enlarged. : there is still present right large pneumothorax with significant collapse of the right lung, left mediastinal chest and left lower lobe consolidation. pneumomediastinum cannot be excluded. the patient is after recent resection of the part of the clavicle and adjacent chest wall debridement. : on the current study, there is evidence of significant decrease in the right pneumothorax with only small amount of pneumothorax is seen. there is still present pneumomediastinum. reexpanding right lung is noted associated with small pleural effusion. left lower lobe consolidation is unchanged. : current study demonstrates bibasal consolidations, bilateral pleural effusions and small amount of pneumothorax is still present as well as potentially small amount of pneumomediastinum. : previous mild pulmonary edema has largely cleared, moderate right pleural effusion is smaller, but bibasilar atelectasis is still severe. no pneumothorax. heart size normal. stomach is moderately distended with air and fluid. medial right clavicle has been resected. : there are low inspiratory volumes. there are small bilateral effusions with underlying collapse and/or consolidation. there is borderline cardiomegaly. there is upper zone redistribution, but no overt chf. the medial aspect of the right clavicle is not visualized, consistent with history of resection, and the medial right clavicle is inferiorly displaced with respect to its normal position. of note, there is some faint opacity in the right suprahilar region, more pronounced than on , which may represent a re-developing pneumonic infiltrate. : persisting bilateral pleural effusion and bibasilar atelectases. stable right suprahilar opacity which likely represents atelectasis/consolidation : stable bilateral pleural effusion and bibasal atelectasis no evidence of pneumothorax : impression: 1. tip of the picc line is 5.4 cm below the cavoatrial junction. 2. stomach has been consistently distended since at least , . such distension might increase the likelihood of aspiration. 3. no acute cardiopulmonary changes compared with last chest x-ray. : mild interstitial edema. left lower lobe atelectasis. no pneumothorax. : impression: little overall change. : findings: in comparison with the earlier study of this date, there again is evidence of increased pulmonary venous pressure, mild enlargement of the cardiac silhouette, bilateral pleural effusions, and evidence of resection of the medial aspect of the right clavicle. central catheter remains in place. dilatation of the gas-filled stomach persists, for which a nasogastric tube might be helpful. : findings: in comparison with the study of , there is little overall change. continued enlargement of the cardiac silhouette with evidence of elevated pulmonary venous pressure and bilateral pleural effusions with compressive atelectasis. evidence of resection of the medial half of the right clavicle is again seen. dilatation of the gas-filled stomach appears to have resolved. : there has been interval decrease in right pleural effusion after positioning of right chest tube. left pleural effusion is unchanged. bibasilar atelectasis are larger on the left side. cardiomegaly is stable. medial chest drains are again noted. surgical clips project in the right medial hemithorax. there are low lung volumes. discharge labs: brief hospital course: patient is a 50 year old female with pmh of asthma, poorly controlled dm1 with last a1c of 13, htn, esrd s/p living related donor renal transplant in , who was admitted for fevers and uti, and found to have pneumonia, vegetative endocarditis and abscesses of chest wall and perinephric growing group b strep. also with acute infarct of rostrum of corpus callosum and possible mycotic aneurisms (neurologically intact), and episodic hypotension. . acute care: . 1. endocarditis: a small vegetation seen on mitral valve with mild mitral regurgitation on . this is the probable origin of septic emboli seeding patient's perinephric abscess and chest wall abscess. microbiology from patient's abscesses grew pcn-sensitive gbs. given patient's history of pcn allergy, she was started on iv vancomycin for coverage of the abscesses. when patient was showing only slow improvement, and there were new findings of infarct of the rostrum of patient's corpus callosum and formation of mycotic aneurisms, it was decided that patient should undergo pcn de-sensitization in the icu and initiate pcn therapy. after treatment with iv pcn, repeat echocardiogram on was unable to revisualize the vegetation, consistent with healing. . 2. right chest wall abscess: patient was found to have a large abscess of the right chest wall involving the soft tissue, clavicle, and first rib and extending to the pleural space. cardiothoracic surgery debrided the abscess and removed infected portions of patient's clavicle and first rib. plastic surgery closed the wound with a flap, and patient was discharged with instructions to follow up in office for suture removal and jp drain removal. iv pcn therapy was administered as definitive treatment for patient's gbs infection. . 3. perinephric abscess: a mass discovered adjacent to patient's grafted kidney was found by biopsy to be an abscess. in the or, the abscess was drained, but there were portions that were not ammenable to drainage. culture of the drainage grew gbs sensitive to pcn, and served as the target organism for antibiotic therapy with regards to patient's multiple areas of infection. repeat imaging showed decrease in size of abscess on discharge. patient was d/c'd with a picc line and instructions to follow up with infectious disease as she is completing pcn therapy at rehab. . 4. infarct of rostrum of corpus callosum and mycotic aneurisms: patient experienced several vasovagal syncopal episodes in house, and during the workup of one of these episodes, the findings of acute infarct of the rostum of the corpus callosum and two areas of probable mycotic aneurism were seen on mra. patient had no neurologic deficits on multiple neurologic exams. felt to be caused by septic emboli from patient's vegetative endocarditis, these lesions were treated with iv pcn as were patient's other infectious foci. . 5. vasovagal episodes: patient had a total of 4 vasovagal syncopal episodes in this hospital stay. patient's heart rate dipped below 40, she lost consciousness and quickly recovered without lasting deficit within minutes each time. two occured after using the bathroom, one ocurred post-surgically, and one occured after eating a large meal and was followed by vomiting. these episodes can be explained by patient's rapidly changing fluid status related to multiple surgeries, and by a degree of relative adrenal insufficiency in the setting of prolonged stress from surgery and infection. telemetry revealed episodic atrial tachycardia, so patient was placed on low dose metoprolol. patient was without further episodes for several days with persistently stable vital signs for several days before discharge. . 6. acute renal failure: on presentation, patient's creatinine was as elevated to 2.2 from baseline 1.1. there was likely an initial component of ain due to nsaid use, but also a pre-renal component related to fluid loss from vomiting and insensible losses on presentation. patient was given iv fluids during her hospitalization and by discharge patient's creatinine recovered to baseline. . 7. anasarca: with multiple surgeries and procedures, and with possible relative ai and low vascular tone in the setting of infection, patient intermittantly required administration of crystalloid solution to support intravascular volume. this led to the accumulation of large lower extremity edema, bilateral pleural effusions, and pericardial effusion. patient also experienced asymetric labial swelling. the right pleural effusion was tapped, a chest tube was temporarily placed, and labs showed transudative fluid so chest tubes were discontinued. with some days of accelerated diuresis with loop diuretics, the pleural effusions, the pericardial effusion, the lower extremity edema, and the labial swelling improved. . 8. oozing of blood from sites of intervention: patient had a drop of hct on and she had oozing of blood from previous sites of intervention including site of chest tube. her plavix, which she was on for throbocytosis and previous episdode of tia, was held for concern of bleeding. given vasocagal episodes in-house concern for fall led to this being held as well, though she was stable and without incident in-hospital for days before discharge. she was discharged with instructions to follow up with hematology for potential re-start of plavix. . chronic care: . 1. s/p living related donor renal transplant. patient was transplanted in . on this stay her tacrolimus was continued. cellcept was held for concern of ptld, but once ruled out and patient was stable, cellcept was restarted. prednisone was continued but at stress dosing and was decreased on discharge. . 2. dm1: a1c 13.6 most recently. the clinic was consulted on this admission and good glucose control was achieved on insulin schedule. . 3. hyperlipidemia: patient was continued on home lipid-lowering . . 4. depression: social work followed patient during this admission. . 5. tia history: patient had an episode of a migraine with neurologic symptoms 2 months ago. she has a history of migraines in the past with blurry vision. mri from , showed punctate focus of slow diffusion in the left posterior frontal lobe consistent with a tiny acute infarct. background mild microangiopathic small vessel disease as well. patient was taking plavix but because of concern for bleed and fall it was held. . transitional care: patient has multiple follow-up appointments to keep with her pcp, , neurology, nephrology, transplant nephrology, hematology, plastic surgery, and clinic. patient should have a repeat head mra around to evaluate status of mycotic aneurisms and infarct of corpus callosum. patient will have follow-up ct scan for imaging of perinephric abscess. patient is to complete pcn g therapy in rehab until . #. contact - patient, her mother is brother, cell or home # full code medications on admission: -atorvastatin 10 mg by mouth once a day -clopidogrel 75 mg by mouth daily -furosemide 20 mg by mouth once a day -metoprolol tartrate 50 mg by mouth four times a day - taking 3x/day -mycophenolate mofetil 1000 mg by mouth twice a day -prednisone 1 mg by mouth once a day -tacrolimus 2 mg by mouth twice a day -insulin regular sliding scale 5 units qam and prn -nph 40units sq qam, 10 units q pm discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. insulin glargine 100 unit/ml solution sig: forty (40) units subcutaneous qam. 3. humalog 100 unit/ml solution sig: one (1) dose subcutaneous qachs: please follow sliding scale. 4. outpatient lab work please check labs - chem-7, cbc, and lfts weekly while patient is on penicillin and have the results faxed to ( 5. penicillin g potassium 20 million unit recon soln sig: 4 million recon solns injection q4h (every 4 hours): until for a course of 6 weeks. . 6. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 7. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). 8. tacrolimus 5 mg capsule sig: one (1) capsule po q12h (every 12 hours). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 12. prednisone 5 mg tablet sig: 1.5 tablets po once a day. 13. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 14. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po four times a day as needed for heartburn. 15. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 16. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po every six (6) hours: hold for sbp<100 or hr<60. 17. nystatin 100,000 unit/ml suspension sig: five (5) ml po four times a day. discharge disposition: extended care facility: - - discharge diagnosis: primary: 1) vegetative endocarditis 2) perinephric and chest wall abscess 3) mycotic aneurism and infarct of rostrum of corpus callosum 4) urinary tract infection 5) pneumonia 6) acute kidney injury secondary: 1) s/p renal transplant 2) type 1 diabetes mellitus 3) hypertension 4) thrombocytosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure taking part in your care. you were admitted to the hospital with 4 days of painful urination and two days of nausea and vomiting. in the hospital we found that you had a urinary tract infection, a growth of bacteria on one of the valves of your heart, and multiple areas of infection related to this. one was around your kidney, another was in your chest wall, and there were a few small areas of the brain that were concerning for infection as well. you were treated with surgery for the chest wall and kidney, and you were treated with penicillin for ramaining infection. repeat imaging was unable to detect growth on your heart valves after receiving treatment. please make the following changes to your medications: stop clopidogrel stop lasix change prednisone to 7.5mg by mouth daily change mycophenolate mofetil to 500mg by mouth twice daily change metoprolol to 12.5mg by mouth every 12 hours change insulin to lantus 40 units in the morning and sliding scale with meals and before bed change tacrolimus to 5mg by mouth every 12 hours start penicillin g at 4million units by iv every 4 hours until start nystatin 5ml by mouth four times daily until please continue all other medications you were taking prior to this admission. please keep all of your follow-up appointments. followup instructions: please follow-up with the following appointments: - please call dr. office for an appointment 2 weeks following discharge from rehab or hospital this is the apopintment with transplant nephrology - please call for an appointment in plastic surgery clinic for drain removal and suture removal. your appointment should take place on the first friday after your discharge. -please call for a confirm your follow-up appointment with dr. , your nephrologist. the appointment has been made, so please confirm date and time. ( department: radiology when: monday at 3:00 pm with: cat scan building: cc clinical center campus: west best parking: garage department: radiology when: monday at 4:20 pm with: xmr building: cc campus: west best parking: garage department: infectious disease when: friday at 10:00 am with: , md building: lm campus: west best parking: garage name: , n. md location: diabetes center address: one place, , phone: appointment: monday 2:30pm please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. department: hematology/bmt when: wednesday at 2:20 pm with: , md building: sc clinical ctr campus: east best parking: garage we are working on a follow up appointment in neurology with dr. and dr. . the office will contact you at home with an appointment. if you have not heard within 2 business days or have any questions please call . md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnostic ultrasound of heart thoracentesis local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] incision of chest wall graft of muscle or fascia advancement of pedicle graft closed [percutaneous] [needle] biopsy of kidney other incision of perirenal or periureteral tissue diagnoses: pneumonia, organism unspecified acidosis hyperpotassemia esophageal reflux cellulitis and abscess of trunk unspecified pleural effusion unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia asthma, unspecified type, unspecified depressive disorder, not elsewhere classified other and unspecified hyperlipidemia unspecified disease of pericardium acute and subacute bacterial endocarditis personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits glucocorticoid deficiency cerebral artery occlusion, unspecified with cerebral infarction syncope and collapse migraine, unspecified, without mention of intractable migraine without mention of status migrainosus other specified hypotension background diabetic retinopathy kidney replaced by transplant diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group b essential thrombocythemia other fluid overload renal and perinephric abscess septic pulmonary embolism acute osteomyelitis, shoulder region unspecified noninflammatory disorder of vulva and perineum 

Answer: The patient is high likely exposed to