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: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral pulmonary embolus major surgical or invasive procedure: inferior vena cava filter midline intravenous catheter cystoscopy history of present illness: other than kidney stones, presents with r side pain and sob. he reports that 4 days of worsening shortness of breath. he was only able to walk 4 steps at a time. prior to this, he was able to accomplish all of his activities of daily living and had not shortness of breath. he denies cough, chest pain, hemoptysis, fever, chills, nausea, vomiting, abdominal pain or back pain. he initially presened to found to have large bilateral saddle pe. there are no records available from , although the pt was started on heparin gtt and transferred to because there were no icu beds at . of note, his creatinine was 2.0. on arrival to ed here t 97.1 p90 165/71 20 94 on 3l. le us was perfomed revealing nonocclusive thrombus in the left common femoral vein. he was admitted to for further mgmt, then to ccu, and finally transferred to medicine for further care. past medical history: nephrolithiasis social history: widower, patient lives alone. no smoking, etoh use daily 1.5 glasses of wine. he drives. family history: mother died of cancer. physical exam: vs: 97.0 axillary / 134/72 / 68 / 18 / 95% 2.5l nc gen: pleasant, alert, normal affect, in no acute distress heent: mmm, op clear, no lad, perrl, eomi chest: cta bilaterally, 8cm jvd heart: irregularly irregular, no m/r/g, no ventricular heave abd: soft, +bs, nd, nt ext: no c/c, no peripheral edema, 2+ dp pulses bilaterally, no calf tenderness bilaterally gu: large right scrotal hernia pertinent results: hematology: 10:00pm blood wbc-10.1 rbc-3.97* hgb-14.5 hct-41.0 mcv-103* mch-36.4* mchc-35.2* rdw-14.4 plt ct-222 05:15am blood wbc-4.9 rbc-3.40* hgb-12.0* hct-33.4* mcv-98 mch-35.2* mchc-35.8* rdw-13.7 plt ct-106* 06:35am blood wbc-3.2* rbc-3.25* hgb-10.9* hct-31.7* mcv-98 mch-33.6* mchc-34.5 rdw-13.7 plt ct-150 06:10am blood wbc-3.9* plt ct-138* 10:00pm blood neuts-88.0* lymphs-6.6* monos-5.2 eos-0.1 baso-0 06:35am blood neuts-53.8 lymphs-35.2 monos-7.6 eos-3.1 baso-0.3 10:00pm blood pt-16.2* ptt-131.4* inr(pt)-1.5* 05:05am blood pt-13.2* ptt-44.7* inr(pt)-1.2* . chemistry: 10:00pm blood glucose-122* urean-46* creat-1.7* na-136 k-6.3* cl-103 hco3-20* angap-19 06:35am blood glucose-85 urean-14 creat-0.9 na-140 k-3.5 cl-106 hco3-29 angap-9 05:26am blood alt-26 ast-39 ld(ldh)-190 ck(cpk)-36* alkphos-76 amylase-23 totbili-0.6 07:50am blood ld(ldh)-153 totbili-0.5 05:26am blood lipase-18 10:00pm blood ctropnt-0.11* probnp-* 01:01am blood ck-mb-notdone ctropnt-0.08* 07:35am blood ck-mb-notdone ctropnt-0.07* 07:35am blood calcium-8.1* phos-2.7 mg-1.9 iron-24* cholest-103 10:15am blood albumin-2.8* calcium-8.1* phos-2.6* mg-2.2 07:35am blood caltibc-150* vitb12-357 folate-6.6 ferritn-420* trf-115* 07:35am blood triglyc-61 hdl-33 chol/hd-3.1 ldlcalc-58 05:20am blood tsh-2.3 11:46pm blood tsh-2.4 10:15am blood cea-1.7 psa-3.5 10:27am blood pep-no specifi rpr non-reactive . urine: creatinine, urine 147 mg/dl total protein, urine 249 mg/dl protein/creatinine ratio 1.7* ratio 0 - .2 . prot. electrophoresis, urine +/- multiple protein bands seen, with albumin predominating' immunofixation, urine - no monoclonal immunoglobulin seen, negative for bence- protein . urine culture (final ): pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. staph aureus coag +. 10,000-100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | cefepime-------------- 8 s ceftazidime----------- 4 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r <=0.5 s imipenem-------------- =>16 r levofloxacin---------- =>8 r meropenem------------- =>16 r nitrofurantoin-------- <=16 s oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- 8 s piperacillin/tazo----- 8 s tetracycline---------- 2 s tobramycin------------ =>16 r vancomycin------------ <=1 s . ecg (): sinus rhythm with frequent atrial premature beats. left axis deviation with left anterior fascicular block. prominent early r wave progression with st-t wave abnormalities in the anterior leads. consider myocardial ischemia versus right ventricular overload. clinical correlation is suggested. no previous tracing available for comparison. . bilateral lower extremity ultrasound (): -scale, color, and spectral doppler analysis of the right and left common femoral, superficial femoral, and popliteal veins was performed. there is no evidence of right lower extremity dvt. there is nonocclusive thrombus extending from the left common femoral vein to the proximal portion of the left superficial femoral vein. the mid and distal superficial femoral veins on the left showed no evidence of thrombus. impression: nonocclusive thrombus extending from the left common femoral vein to the proximal portion of the left superficial femoral vein. no evidence of right lower extremity dvt. . tte (): 1. the left atrium is mildly dilated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. a small pulmonary av shunt is probably present. 2. the left ventricular cavity size is normal. there is severe global left ventricular hypokinesis. overall left ventricular systolic function is severely depressed. 3. the right ventricular cavity is dilated. there is severe global right ventricular free wall hypokinesis. 4. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. 5. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 6. there is mild pulmonary artery systolic hypertension. 7. there is a small, loculated (apical) pericardial effusion with fibrin deposits on the surface of the heart.. . ct abdomen/pelvis with contrast (): 1. very large bowel-containing right inguinal/scrotal hernia without evidence of obstruction or ischemia. 2. thickening of the bladder wall with possible intraluminal blood clots. 3. small bilateral pleural effusions and pericardial effusion. 4. no intraabdominal mass or lymphadenopathy. . bladder ultrasound study (): numerous images of the bladder demonstrate a diffusely abnormal wall with irregular thickness and contour, predominantly on the anterior aspect. some areas of the irregularly thickened anterior wall demonstrate increased vascularity. there is echogenic fluid in the bladder with debris seen in the dependent portion, some of which is mobile. impression: irregularly thickened bladder wall, most pronounced anteriorly with small areas of increased vascularity. given the appearance of the wall, a cystoscopy is recommended to exclude malignancy. . ct head without contrast (): findings: there is no intracranial hemorrhage. there is no midline shift, mass effect, or hydrocephalus. there are areas of low attenuation within the periventricular white matter, most consistent with chronic microvascular ischemic change. the -white matter differentiation is preserved. there are no fractures. impression: no intracranial hemorrhage. no mass effect. . tte (): the left atrium is moderately dilated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef 60-70%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , contractile function of the right ventricle is now normal. the left ventricle was poorly visualized on the prior study, but was probably normal. . urine cytology (): negative for malignant cells. no urothelial cells seen. predominantly neutrophils. red blood cells. . cystoscopy (): (per dr. note) 3+ trabeculated bladder. bladder stone. no evidence malignancy. brief hospital course: 78m with no known past medical history originally p/w cp & sob, found to have saddle pes, arf, and urinary retention. patient arrived to the ed from with known bilateral saddle pulmonary emboli. he was continued on heparin, started on iv fluids, and transferred to the ccu given evidence of heart failure on echo (ef 25%, rv dysfunction). an us of his lower extremities showed a clot in his left common femoral vein. he was anticoagulated. on day 2 of his hospital course, a removable ivc filter was placed successfully without complications. the patient developed agitation and delerium, threatened to leave ama, but was deemed not competent to make medical decisions. guardianship was pursued and evenutally decided on . his course was also complicated by uti for which he received antibiotics. see below for further details. course on the floor as follows: #) bilateral saddle pes: presented with cp and sob, found to have bilateral pes and dvt with evidence of heart failure and rv dysfunction. anticoagulated with heparin and then coumadin briefly but then d/c'd coumadin in favor of lovenox as planned for inpaitent cystoscopy for malignancy workup (see below). s/p ivc filter on given dvt present and concern for further embolization. he was continued on lovenox for anticoagulation until cystoscopy performed and then started on coumadin. he will continue lovenox until reaches goal inr at which time coumadin can be discontinued. following resolution of the acute issues, he has remained hemodynamically stable with no respiratory complaints. discussed removal of ivc filter with ir but they believe high likelihood of failure and procedural risks so deferred. further hypercoagulability evaluation deferred to outpatient. followup with pcp. patient will need daily inr checks until therapeutic on coumadin at which time lovenox can be discontinued. . #) dementia, agitation, altered mental status: patient was very agitated, confused early in hospital stay. likely etiology was toxic-metabolic acute illness and urinary infection in the setting of chronic dementia. improved somewhat with resolution of acute medical problems but not completely. he repeatedly attempted to leave ama and required code purple intermittently with physical restraints. psychiatry was consulted and the patient was started on standing haldol with improvement and resolution of his agitation. there was concern regarding his ability to understand his illness, comply with treatment, and care for self. he required a 1:1 sitter due to flight risk and occasional agitation. guardianship was established (see below). at discharge the patient was calm, cooperative, and conversant. . #) urology: uti, urinary retention, acute renal failure, abnormal bladder ultrasound. on hospital day 4 the patient developed a uti. he was initially treated with ceftriaxone, which was then switched to ciprofloxacin. his foley catheter was removed, but patient developed urinary retention with drainage of 1.4l from his bladder. renal failure was likely post-renal due to obstruction and resolved with drainage of bladder. urology was consulted for very difficult foley placement and he was started on flomax. psa was normal. the foley was initially left in place due to the difficulty of placement and the fact that he was asymptomatic; he was continued on ciprofloxacin, but he developed symptoms of bladder irritation on . repeat urine culture grew pseudomonas resistant to quinolones and mrsa. ciprofloxacin was discontinued and ceftazadime and vancomycin were started to complete a 2 week course (started on and , respectively). a midline catheter was placed and should be removed on after completing his course of iv antibiotics. he failed two voiding trials the week prior to discharge and therefore an indwelling foley was left in place with urology followup for urodynamics studies and consideration of turp. also found to have bladder u/s with irregular wall thickening. concern was for malignancy, however urine cytology was negative and the patient underwent cystoscopy on which revealed no evidence of malignancy. plan for outpatient urology followup with dr. on . . #) malignancy screening: given hypercoagulability, initiated cancer screening as possible etiology. abdominal/pelvic ct was notable for a thickened bladder wall and further followed up with a bladder us that confirmed the finding. urine cytology and cystoscopy was negative. chest ct at presentation showed bibasilar nodular densities in the setting of bilat pes, and repeat study revealed that these had completely resolved. however, an indicental finding of hypoattenuating liver lesion was noted that should be followed up with mri per radiology as an outpatient. he was also scheduled for screening colonoscopy with dr. ; instructions for the bowel preparation are attached with the discharge information. followup with urology per above. . #) thrombocytopenia: platelets 222 on arrival, and noted slow downward progression during initial hospital course with nadir in low 100s. possibly consumption for underlying blood clots, but not clear. hematology was consulted. did not appear to meet trends for either type i or ii hit; hit antibody was sent and was negative. no other signs of dic, ttp. initially on heparin, then coumadin, and finally lovenox. discontinued protonix secondary to small likelihood that ppi/h2 blockers cause thrombocytopenia. platelets slowly increased and normalized around 150. would continue to monitor weekly as outpatient. . #) cardiac: no known cad and on no cardiac meds at home. upon arrival, echocardiogram initially with ef 25% and rv dysfunction likely pe, so acei and bb were initiated for presumed cardiomyopathy. repeat echo was performed after acute events resolved and showed preserved ef with normal wall motion. acei and bb were then discontinued. he remained in sinus rhythm, normotensive. euvolemic on exam. ambulating wihtout difficulty. no further issues. . #) scrotal hernia: large scrotal hernia noted on exam, althogh patient asymptomatic. abdomen/pelvis ct scan with large amount of bowel in hernia sac. no evidence of incarceration, volvulus. patient declining eval for herniorraphy and given no symptoms unlikely need at this time. monitor as outpatient with surgery referral as indicated. . #) disposition: on , the patient appeared to be medically clear discharge, however it was clear that patient was not safe to go home given limited mobility, anticoagulation, lack of social supports, and extremely limited understanding of his condition. he was deemed to lack capacity to understand risks/benefits of refusing care and inability to care for self at home safely. in addition, it was discovered that his home was condemned by public health department. as a result, guardianship was pursued with family and his attorney. official guardianship appointed between , jd and (cousin; ). medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever or pain. disp:*60 tablet(s)* refills:*0* 2. hexavitamin tablet sig: one (1) cap po qam (once a day (in the morning)). disp:*30 cap(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po bid prn as needed for constipation. disp:*60 tablet(s)* refills:*0* 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). disp:*90 tablet, chewable(s)* refills:*2* 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. docusate sodium 100 mg capsule sig: two (2) capsule po bid prn. disp:*60 capsule(s)* refills:*2* 7. haloperidol 0.5 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 8. haloperidol 1 mg tablet sig: one (1) tablet po hs (at bedtime). 9. ceftazidime-dextrose (iso-osm) 1 g/50 ml piggyback sig: one (1) gram intravenous q8h (every 8 hours) for 5 days. 10. heparin flush midline (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 11. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 12. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 7 days. 13. enoxaparin 60 mg/0.6 ml syringe sig: sixty (60) mg subcutaneous twice a day: discontinue when inr >2. 14. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po at bedtime. 15. warfarin 7.5 mg tablet sig: one (1) tablet po hs (at bedtime). tablet(s) discharge disposition: extended care facility: - discharge diagnosis: primary: 1) bilateral saddle pulmonary emboli 2) delirium 3) alcohol withdrawal 4) dementia 5) urinary retention 6) complicated urinary tract infection 7) thrombocytopenia nos . secondary: 1) macrocytic anemia 2) history of alcoholism 3) hypertension 4) lung nodules nos discharge condition: good discharge instructions: please take all medications as prescribed. . call your doctor or return to the ed immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. followup instructions: you are scheduled for the following appointments. please contact the provider with any questions or if you need to reschedule. . pcp: . . , , , ma. (. at 1:30pm. you were found to have a possible abnormality in your liver. it was suggested that you have an mri of your liver for further evaluation. you will need to be accompanied by an attendant or your guardian. . urology: , md. . phone: date/time: 3:10. followup for urodynamics studies and consideration of possible turp procedure. . colonoscopy: gi west,room one gi rooms date/time: 10:30 gastroenterology: , md phone: date/time: 10:30. colonoscopy. you must arrive by 9:30am. you will need to complete a bowel prep starting the day before this appointment. please see the sheet given to you at discharge for instructions on how to perform the preparation. procedure: venous catheterization, not elsewhere classified interruption of the vena cava other cystoscopy diagnoses: thrombocytopenia, unspecified urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified infection with microorganisms resistant to penicillins other persistent mental disorders due to conditions classified elsewhere methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site retention of urine, unspecified acute venous embolism and thrombosis of deep vessels of proximal lower extremity other pulmonary embolism and infarction other and unspecified alcohol dependence, continuous alcohol withdrawal delirium inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) calculus in diverticulum of bladder 

Answer: The patient is high likely exposed to