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: fever and hypotension major surgical or invasive procedure: diagnositic and therapeutic paracentesis picc line placement skin biopsy bronchoscopy bone marrow biopsy wound care history of present illness: 67 yo male w/ mds with recent admission from to surgical service for r. hemicolectomy with end ileostomoy and mucous fistula admitted on with sirs/early sepsis with unknown source of infection. . admission was for evaluation for bilateral erythema/blisters on arms after injections/ treatment with im vidaza for his mds on . his hospital course was complicated by necrotic bowel and an exp lap was performed with hemicolectomy and end ileostomy and mucous fistula (). he required intubation for respiratory distress and cardioversion for atrial fibrillation. also developed vre (sensitive to daptomycin) in peritoneal fluid, discharged on daptomycin. . er visits and : presented with concern of infected wound dehisence, evalutated by surgery, discharged with bactrim and keflex for presumed wound infection and concomittant uti. represented the following day with hypotension, fever, hct of 21 and inr of 8. received total 6 units prbc, 1 unit ffp and ivf, vitk. rt ij placed, started on dapto/zosyn. . sicu admission : presentation notable for skin lesion, fever, hypotension, hct drop, and elevated inr. he was continued on daptomycin and pip-tazo. the patient has had volume responsive hypotension with no current pressor requirement. he underwent u/s-guided paracentesis w/ removal of 2700cc. he was found to have erythema surrounding his abd incision with an additional erythematous nodule on the r thigh. the etiology of the patient's presentation has been unclear, however possible infectious sources include a secondary wound infection vs. hematogenous spread of an alternate underlying infection. the patient's skin findings are felt to be more consistent with inflammatory etiology (as opposed to infectious etiology). prelim biopsy for hip and peri-incisional biopsies read as neutrophilic dermatosis (pyoderma gangrenosum), though cannout rule out infectious process. . upon admission to patient reports intermittent abdominal pain mid-abdomen fluctuating in intensity , no radiation. occasional nausea, no vomitting. ostomy output loose and brown. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations. he feels generalized weakness. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. past medical history: myelodysplastic syndrome, carpal tunnel syndrome, copd. past surgical history: l knee surgery, back surgery. social history: retired, used to work for a chemical company. history of asbestos and other chemical exposure. he has a history of significant alcohol use, which he stopped approximately seven years ago. 60 pack year history of tobacco use. has a daughter. lives alone. was going to the gym every other day and walking 4 miles before his necrotic bowel surgery. family history: per med record: sister - died of scleroderma; another sister - died of unclear etiology; brother - died of etoh abuse; daughter with marfan's; two brothers are alive and well; mother - died of lung cancer; father - died in an mvc. physical exam: gen: no acute distress, lying in bed heent: dry mucous membranes with white plaque on tongue. no lad. lungs: coarse breath sounds, expiratory wheezing on right, rhonchi anteriorly, with bibasilar crackles bilaterally cv: tachycardic, regular rhythm, normal s1 s2, no m/g/r. r ij site c/d/i back: no focal tenderness, no cvat gi: abdomen with large midline open incision extended from pubic symphisis to subxiphoid with serosanguinous drainage. ostomy with dark necrotic appearing mucosa. gu: foley in place draining yellow urine. msk: no joint swelling or erythema ext: trace pitting edema bilaterally skin: mucocutaneous fistula site with necrotic center. 2cm nodular lesion on lateral aspect of r thigh with surrounding erythema, warm, and tender to touch. neuro: cn2-12 grossly intact, ue 5/5 strength, le rle strength and lle able to lift against gravity. pertinent results: labs upon admission: 06:35pm blood wbc-8.0 rbc-2.38* hgb-7.7* hct-21.9* mcv-92 mch-32.2* mchc-34.9 rdw-18.4* plt ct-70* 06:35pm blood neuts-79.2* bands-0 lymphs-13.0* monos-3.9 eos-3.6 baso-0.2 05:37am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-normal ovalocy-1+ schisto-occasional 06:35pm blood pt-51.0* ptt-45.9* inr(pt)-5.6* 04:51am blood fibrino-625* 03:33am blood gran ct-1794* 04:51am blood ret aut-3.1 03:33am blood aca igg-pnd aca igm-pnd 06:35pm blood glucose-108* urean-19 creat-1.1 na-129* k-4.0 cl-96 hco3-26 angap-11 04:51am blood alt-24 ast-29 ld(ldh)-132 alkphos-78 totbili-2.0* 06:35pm blood probnp-1421* 04:51am blood albumin-2.4* calcium-7.2* phos-4.2 mg-1.7 04:51am blood hapto-268* 10:40pm blood ferritn-3219* 10:40pm blood triglyc-79 04:02am blood osmolal-283 04:02am blood tsh-2.4 04:02am blood cortsol-33.7* 03:33am blood anca-negative b 03:33am blood -negative 04:44am blood type-central ve po2-85 pco2-38 ph-7.46* caltco2-28 base xs-2 comment-green top 06:46pm blood glucose-107* lactate-1.3 na-130* k-4.1 cl-94* calhco3-27 06:46pm blood hgb-8.1* calchct-24 04:44am blood freeca-1.00* labs upon discharge: wbc rbc hgb hct mcv mch mchc rdw plt ct 00:10 1.8* 2.80* 8.1* 24.3* 87 28.9 33.4 13.8 26* platelets post transfusion: 54* glucose urean creat na k cl hco3 angap 00:10 103*1 35* 0.6 136 4.3 98 33* 9 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 00:10 30 15 161 60 0.5 chemistry totprot albumin globuln calcium phos mg uricacd iron 00:10 3.5 8.7 3.0 2.1 autoantibodies anca 03:33 negative b1 old s# c negative by indirect immunofluorescence immunology 03:33 negative b-glucan, galactomannan: negative . cxr : small bilateral pleural effusions. equivocal signs for mild pulmonary vascular congestion. otherwise, unremarkable. . ct abdomen : 1. large volume ascites with mild peritoneal enhancement in the right paracolic gutter. overall appearance appears simple though given history of recent surgery, peritonitis cannot be excluded. consider paracentesis with culture. 2. post operative changes rel;ated to recent bowel resection without evidence of bower obstruction or perforation. 3. small bilateral pleural effusions with bilateral lower lobe compressive atelectasis. . right hip skin biopsy : the findings in both specimens are similar, with intense neutrophilic infiltration of the dermis. the overlying epidermis exhibits neutrophilic spongiosis with foci of spongiform pustulation; in specimen 2, frank cleavage is noted through the spinous layer. no micro-organisms are identified within the inflamed tissue in pas, gms, and gram stained sections . paracentesis: technically successful diagnostic and therapeutic paracentesis yielding 2.7 liters of amber clear ascitic fluid, which was sent for microbiology and cell count. . liver/ruq ultrasound : ascites. sludge within the gallbladder. no gallstones. no dilated bile ducts. no focal lesions seen in the liver. assessment was limited to the liver, gallbladder and related structures. . cxr : in comparison with the study of , there are continued low lung volumes. persistent enlargement of the cardiac silhouette with some indistinctness of pulmonary vessels consistent with some elevation of pulmonary venous pressure. probable mild bilateral effusions with compressive atelectasis. silhouetting of the left hemidiaphragm is consistent with substantial volume loss in the left lower lobe. . pertinent imaging after icu: . paracentesis: impression: successful uncomplicated therapeutic and diagnostic ultrasound-guided paracentesis of 1.2 liters of clear ascites. fluid was sent for gram stain, culture, cell count, protein, ldh and albumin. . ct torso: 1. multifocal ground-glass pulmonary opacities, most compatible with multifocal infectious process. new left lower lobe collapse. 2. small-to-moderate bilateral pleural effusions, left greater than right, appear simple. 3. unchanged moderate volume ascites, with mild peritoneal enhancement again seen in the right paracolic gutter. this may again be post-surgical, though clinical correlation is advised to exclude peritonitis. 4. unremarkable appearance of the large and small bowel, status post right hemicolectomy, with end ileostomy and mucous fistula in the right abdomen. no evidence of abscess formation. 5. splenomegaly 6. anasarca. . ct chest: 1. markedly improved multifocal lung opacities. the largest area that remains is in the left upper lobe. 2. mild increase in size in moderate left pleural effusion. resolved left lower lobe collapse. 3. splenomegaly . mri pelvis: 1. no interval change in the free fluid within the abdomen and pelvis but no abscess seen. 2. bilateral avn, more significant on the right side. 3. extensive subcutaneous edema. . pathology: r buttock skin biopsy: superficial and deep perivascular, periappendageal and interstitial dermatitis with prominent neutrophils and overlying papillary dermal edema, epidermal hyperplasia, and spongiosis. see note. note: the depth of the infiltrate is suggestive of an infection such as bacterial cellulitis. the histologic pattern is not typical of those observed with deep fungal or atypical mycobacterial infections (unless inflammation is more prominent deep to the tissue sampled in this biopsy). the depth of the infiltrate and lack of a more florid neutrophilic infiltrate are unusual for sweet's syndrome, however, a variety of neutrophilic inflammatory patterns may be observed in patients with myelodysplastic syndrome (mds) and in association with g-csf (if clinically applicable). the inflammation is peri-eccrine in areas and focally there are neutrophils involving eccrine units. this finding raises consideration of a neutrophilic eccrine hidradenitis (neh) in the differential diagnosis. neh may be observed in association with chemotherapeutic agents and g-csf. it was recently reported to occur with decitabine, a derivative of azacytidine (vidaza). . special stains (gram, , pas, and gms) are negative for organisms. culture may be a more sensitive method to detect organisms than histologic special stains. in summary, if infection is excluded, the differential diagnosis includes a neutrophilic infiltrate associated with mds or a drug associated neh. preliminary results of this case were discussed with dr. on . . microbiology cultures: peritoneal: 2:14 pm peritoneal fluid gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. . time taken not noted log-in date/time: 3:58 pm peritoneal fluid source is peritoneal fluid. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. . tissue cultures: time taken not noted log-in date/time: 4:01 pm tissue source: skin biopsy. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (final ): no growth. potassium hydroxide preparation (final ): no fungal elements seen. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. . time taken not noted log-in date/time: 4:01 pm tissue source: skin biopsy. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (final ): no growth. potassium hydroxide preparation (final ): no fungal elements seen. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. . 12:10 pm rapid respiratory viral screen & culture **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): respiratory viral antigen test is uninterpretable due to the lack of cells. refer to respiratory viral culture for further information. reported by phone to dr 11:05am . . 12:10 pm bronchoalveolar lavage gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. potassium hydroxide preparation (final ): koh requested per dr. pg #. no fungal elements seen. this is a low yield procedure based on our in-house studies. . immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. . please see omr for bc/uc results. all negative with uc < 100,000 cfu. . bone marrow biopsy: completed follow up. brief hospital course: 67 y/o male with mds s/p r. hemicolectomy with end ileostomy/mucous fistula on , who presented with fluid responsive hypotension and fever. . sirs/sepsis/fever: upon admission he was intermittently febrile, and his hyoptension was fluid responsive. he did not require vasoactive medication. possible etiologies included uperinfection of right thigh lesion with neutrophilic dermatosis, post-operative wound infection with wound dehiscence. ct torso was completed without evidence of intraabdominal abscess. he was started on daptomycin and zosyn, later stopped zosyn due to low platelets, switched to ciprofloxacin and flagyl, then finally broadened to meropenum. discharged from micu on daptomycin (6 total days given in micu) and meropenum (2 days given in micu). he was also empricially covered with meropenem. an infectious cuase for the hypotension was never identified by culture or by serology. id followed the patient throughout his hospital course, and eventually recommended d/c his antibiotics after his new diagnosis of sweet's syndrome. additionally, a workup was also completed including , anca, and anti-cardiolipin out of concern for underlying autoimmune process that could explain the etiology of his fevers. rheumatology was also consulted, and did not did not recommend any additional work up for his fevers. the most likely etiology for the hypotension was secondary to a wound infection and sepsis. . #mds/pancytopenia: upon admission to the hospital his counts steadily dropped throughout his stay in the micu. there was initial concern for leukemia in his bone marrow. hemolysis labs were negative. reticulocyte count was low. hit antibody was negative. the differential diagnosis included worsening mds, aml progression, or other hematopeoieic malignancy. hemolysis and smear analysis did not suggest dic. his counts remained low throughout the hospital course and his wbc count continued to flucuated. he was supported with prbc's and platelets. he had a bm biopsy prior to discharge and his last anc was 790. - please transfuse prbc's for hct < 25. - please transfuse platelets for count < 10 or active signs of bleeding when < 30. - he will need bactrim, and acyclovir for ppx due to his low wbc. . #sweet's syndrome/neutrophilic dermatosis: he was found to have an erythematous nodule on his right leg and pain. a skin biopsy was sent which was consistent with neutrophilic dermatosis. based upon the biopsy in addition to his clinical findings, a diagnosis of sweet's syndrome was proposed to explain his high grade fevers in addition to his skin lesions. corticosteroid treatment was not initiated until multiple imaging studies confirmed that there was no infectious process or abscess in his abdomen after his recent surgery. multiple cultures, both urine and blood, were negative. a bronchoscopy was also preformed after a ct revealed multiple opacities. subsequently, the bal was only positive for yeast which was thought to be a non-pathological. the pulmonology consult team felt that the infiltrates and skin findings were consistent with sweet's syndrome. he also developed another sight of pain adjacent to his r sacrum that also had a neutrophilic infiltrate, but not to the degree of the r thigh skin biopsy. the differential diagnosis was neutrophilic dermatosis vs. neutrophilic eccrine hidradenitis. based upon his clinical symptomology, he was treated empirically for sweet's syndrome with methylprednisone 1 mg/kg with a slow week taper to 0.5 mg/kg. he was then started on oral prednisone 50 mg/day. he was also started on gi prophylaxis with famotidine, vit d, and calcium. a non-contrast ct of the lungs demonstrated improvement of his multi-focal opacities, his skin lesions continue to heal, and he has been afebrile since the initiation of steroids. - please continue prednisone 50 mg/day. do not taper dose. his steroid course will be determined by dr. as an outpatient. - please continue ca/vit d and famotidine for steroid prophylaxis - please continue po dilaudid for pain, may wean as patient tolerates . # end ileostomy/mucous fistula s/p hemicolectomy: he presented with wound dehisence. his intial presentation may have been secondary to infection of his wound. he was initially started on broad spectrum antibiotics with minimal improvement in his wound healing. after the initiation of corticosteroids for sweet's syndrome the erythema along the margins of his wound improved. he subsequently developed granulation tissue, and his wound continues to demonstrate healing. - please continue daily wound care as outlined in attached notes - scheduled for follow up as outlined above . hyponatremia: the patient had persistent hypnatremia that was secondary to hypervolemia due to fluid resuscitation, and sweet's syndrome with siadh due to infilatrates in the lung. urine osms were consistenly elevated relative to osms. his sodium remained > 128 while on the floor. he was placed on fluid restriction and subsequently allowed to autodiuresis. his sodium level stabilized and he was no longer fluid restricted. - no fluid restriction . # hyperglycemia: his sugars have been monitor qid, and he has been placed on an iss with lantus to help regulate his blood glucose levels. his sugars have flucuated between 150's -200's. - please keep blood glucose less than 180's. . # decreased hearing: patient had large cerumen plug in left ear. patient received ear drops which were ineffective. his ear canals were clear by examination, and ent was consulted for hearing loss. it was believed to be sensorineural, and an audiology test confirmed the hearing loss in his r ear. he will be followed up by ent for a hearing aide. . # ascites: he had a paracentesis on with removal of 2.7l of fluid which did not demonstrate any infection. he had an additional paracentesis which did not reveal sbp. he continues to have ascites without any evidence of infection. although the volume decreased throughout his hospital stay. it was thought that his ascites may have been secondary to his poor nutritional status upon presentation when his albumen was < 3.0. . # stage ii decubitus ulcer: currently has a stage ii decubitus ulcer. - continue wound managment . # incidential avn (bilateral based upon mri). he had an mri of the pelvis and legs which demonstrated avn. - will need follow up as an outpatient . # history of afib w/rvr: patient had atrial fibrillation during his last hospital admission. he was in sinus rhythm during this admission, and prior to discharge. his amiodarone was discontinued. . # copd: hed did not have any evidence of an acute exacerbation of copd - continue albuterol inhalers prn medications on admission: 1. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for to groin. 2. silver sulfadiazine 1 % cream sig: one (1) appl topical with each dressing change (). 3. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheeze. 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day). . medications (on transfer to micu): ondansetron 4 mg iv q8h:prn nausea micafungin 100 mg iv q24h ciprofloxacin 400 mg iv q12h fentanyl citrate 25-100 mcg iv q2h:prn pain acetaminophen 1000 mg po/ng q6h:prn fever albuterol inhaler 2 puff ih q4h famotidine 20 mg iv q12h insulin sc (per insulin flowsheet) daptomycin 600 mg iv q24h piperacillin-tazobactam 4.5 g iv q8h discharge medications: 1. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 2. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough/sputum. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for sob/wheeze. 4. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever, pain. 6. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 7. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 8. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 9. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 10. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (we). 11. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. insulin glargine 100 unit/ml solution sig: one (1) 23 units subcutaneous at bedtime. 13. humalog 100 unit/ml solution sig: one (1) variable subcutaneous four times a day: iss, please see attached. 14. prednisone 50 mg tablet sig: one (1) tablet po daily (daily). 15. hydromorphone 4 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 16. sodium chloride 0.9 % 0.9 % syringe sig: three (3) ml injection q8h (every 8 hours) as needed for line flush. 17. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 18. ondansetron 4 mg iv q8h:prn nausea 19. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. 20. sodium chloride 0.9 % 0.9 % syringe sig: ten (10) ml injection prn (as needed) as needed for line flush. 21. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dryness. discharge disposition: extended care facility: discharge diagnosis: primary diagnosis mds secondary diagnosis sweet's syndrome ascities hyponatremia avn bilaterally hyperglycemia poor wound healing discharge condition: mental status: clear and coherent. activity status: ambulatory - independent. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear , thank you for receiving your care at hospital. you were admitted for low blood pressure neccessitating and icu stay and a new diagnosis of sweet's syndrome. you were initially given antimicrobial therapy for high fevers, however, no infectious source was cultured. you also had numerous imaging studies which did not reveal an infectious collection of fluid. several lesions on your skin were biopsied which showed an inflammatory infiltrate. after the biopsy results returned, you were started on steroids. you will need a slow taper of steroids. you will need to go to a rehab facility to help improve your physical strength. . the following medications were added to your regiment: lantus humalog prednisone hydromorphone vitamin d (weekly) calcium carbonate acyclovir bactrim famotidine trazadone guaifenesin zofran artificial tears . the following medications were stopped: amiodarone oxycodone-tylenol heparin silver sulfadiazine . the following medications were changed: none followup instructions: please come to the medical complex for the following appointments: 10:30a , t lm , otolaryngology/audiology (nhb) 02:00p acute lm bldg (), surgical assoc lmob-3a (sb) 01:45p ,teaching sc clinical ctr, clinic-cc2 (sb) 12:30p , e. sc clinical ctr, hematology/oncology-sc 12:30p , h. sc clinical ctr, hematology/oncology-sc procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified percutaneous abdominal drainage percutaneous abdominal drainage biopsy of bone marrow closed [endoscopic] biopsy of bronchus closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue diagnoses: other postoperative infection cellulitis and abscess of trunk urinary tract infection, site not specified unspecified septicemia hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified atrial fibrillation sepsis myelodysplastic syndrome, unspecified other specified cardiac dysrhythmias other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation pressure ulcer, lower back accidents occurring in other specified places disruption of external operation (surgical) wound pressure ulcer, stage ii chronic ulcer of other specified sites non-healing surgical wound other specified erythematous conditions surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation 

Answer: The patient is high likely exposed to