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 attending: chief complaint: hyponatremia. major surgical or invasive procedure: 1. intubation and mechanical ventilation 2. central venous catheter 3. arterial line history of present illness: 84 year-old female pmh dm, htn, hyperlipidemia brought to the ed by her children for difficulty urinating. history mainly done through her son. reports she complained of fatigue since yesterday then this morning difficulty urinating. she described the sensation as needing to urinate but unable. her daughter reported hematuria - however on further questioning this was on the toilet paper only so unclear whether urinary or gi related. otherwise patient has been her usual state of health. she has had a chronic non-productive cough for the past month but not increased recently in severity. denies fevers and chills. denies sick contacts. denies shortness of breath or chest pain. denies abdominal pain, nausea and vomiting. reports having regular bm (today and yesterday). does describe a decreased appetite in the last week. no lower extremity edema, orthopnea or pnd. . in the ed, initial vs t 97.9, hr 77, bp 175/85, rr 18, o2 sat 93%. patient then triggered for hypoxia with o2 sat 83% ra which improved with nasal canula. abdominal exam notable for distention - when foley was placed 200cc urine returned and patient felt better. patient was guaiac negative with no stool in the vault. ct ab/pelvis was done which demonstrated cholelithiasis, small amount of free fluid in the pelvis but otherwise unremarkable. ct chest demonstrated moderate bilateral pleural effusions, bilateral basilar consolidations l > r concerning for aspiration versus pneumonia. patient was treated with levo/flagyl, 1 l ns. bedside echo demonstrated enlarged right ventricle and due to high bnp in setting of hypoxia cta was done which was negative for pe. labs notable for na 111, lactate 1.3, wbc 12.5 (n 80, l 10.2), hct 30.5. mental status reported as agitated. patient hypertensive throughout her stay. vs on transfer bp 138/94, hr 94, rr 24, o2 96% 4 l. . past medical history: 1. dm. dx'd ~. followed by dr. of endocrine. 2. htn. dx'd ~. 3. high chol. 4. pulmonary tuberculosis in . treated w/ ethambutal, rifampin, pyrazinamide, and inh. 5. osteoporosis. unsure when last bmd was. 6. a fib - per omr - family unaware social history: lives alone, son and daughter live close by and check in regularly. born and raised in . came to us in . has 5 children. used to work running a department store in . family history: non-contributory. physical exam: on admission: vitals: t: 97 bp: 135/58 hr: 105 rr: 16 o2sat: 98% 4l gen: eldery female in no acute distress heent: dry mucus membranes, eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, op clear neck: no jvd cor: irregular rhythm, no m/g/r pulm: decreased breath sounds at bases, diffuse wheezes abd: soft, mildly distended, decreased bowel sounds, no hsm, no masses. ext: no c/c/e, no palpable cords neuro: alert, according to family oriented to person, place, and time. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. . at discharge: pertinent results: . micro: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and singly. 1+ (<1 per 1000x field): multiple organisms consistent with oropharyngeal flora. 1+ (<1 per 1000x field): budding yeast with pseudohyphae . 3:23 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): no growth. urine culture (final ): no growth. negative for legionella serogroup 1 antigen. . urine urine culture-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient sputum gram stain-final; respiratory culture-final inpatient sputum gram stain-final; respiratory culture-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient sputum gram stain-final; respiratory culture-final inpatient urine legionella urinary antigen -final inpatient mrsa screen mrsa screen-final inpatient urine legionella urinary antigen -final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final emergency . ecg: hr 95. normal axis. irregular rate - a fib. no st elevations/depressions. no old for comparison. . cta chest and ct abd/pelvis- impression: 1. widespread centrilobular nodules in a tree-in- distribution in the right lung, with possible small cavitating nodules in the right lower lobe. findings are compatible with a small airways infectious process, and endobronchial spread of tuberculosis is within the differential. mediastinal and right hilar lymphadenopathy are likely reactive. 2. fibrotic changes within the right lung apex compatible with history of prior tuberculosis. 3. 2-cm left upper lobe subpleural consolidative opacity could represent an area of infection, but neoplasm is not completely excluded. 4. 4. no pulmonary embolism or acute aortic pathology. 5. no diverticulitis. no small bowel obstruction. 6. tracheobronchomalacia. 7. marked coronary artery disease. 8. bilateral small-to-moderate sized pleural effusions. 9. significant gallbladder edema in a nondistended gallbladder. this finding could be secondary to third spacing or reflection of underlying liver disease. 10. severe l1 compression fracture, likely chronic. . tte (): the left atrium is elongated. a small secundum atrial septal defect is present as detected by color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a very small pericardial effusion. . cxr (): the et tube tip is 6 cm above the carina. the ng tube tip is in the stomach. the right internal jugular line tip is at the level of mid svc. the cardiomediastinal silhouette is stable. multiple perihilar interstitial opacities that have developed in the interim are new and consistent with worsening interstitial edema. the left lateral consolidation seen back on has gradually decreased . bronchiectasis volume loss and chronic fibrotic changes in the right upper lung are demonstrated. bilateral pleural effusion is at least moderate, unchanged. no pneumothorax is seen. . cxr -findings: a single portable ap radiograph was obtained. atelectatic changes are presenet at the left base with blunting of the left costophrenic angle suggestive of a small amount of pleural fluid, unchanged from prior study. the right lung is relatively clear with no evidence of pneumonia or chf. no pneumothorax is present. the heart and mediastinal contour are normal. impression: stable appearance of the chest . ct head -impression: 1. no evidence of acute intracranial hemorrhage or fracture. 2. small vessel ischemic disease. 3. mild age-related involutionary changes. . hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 07:05 10.4 2.69* 8.0* 24.6* 92 29.7 32.4 12.3 335 07:55 10.1 2.88* 8.1* 26.6* 92 28.2 30.7* 12.5 301 08:00 8.9 3.04* 8.9* 27.8* 92 29.3 32.0 12.3 294 06:27 8.8 2.93* 8.5* 27.1* 93 29.1 31.5 12.1 251 06:46 10.4 2.79* 8.1* 26.5* 95 29.2 30.7* 12.4 248 08:00 14.7* 2.98* 8.9* 27.9* 94 29.8 31.7 12.3 302 12:38 11.8* 3.07* 8.8* 28.6* 93 28.7 30.8* 12.3 298 06:50 10.6 3.58* 10.4* 32.5* 91 29.1 32.1 12.0 464* 05:39 8.9 3.17* 9.2* 29.4* 93 29.1 31.4 11.9 396 source: line-cvl 04:46 7.6 3.47* 10.1* 31.9* 92 29.2 31.7 12.0 456* source: line-cvp 22:57 9.7 3.38* 9.8* 30.5* 90 29.0 32.1 12.0 450* source: line-central line 06:45 10.9 3.42* 10.2* 31.1* 91 29.8 32.7 12.1 503* source: line-right ij central line 02:13 10.2 3.20* 9.5* 28.8* 90 29.7 33.0 12.2 393 source: line-central line 04:45 12.3* 3.29* 9.8* 28.6* 87 29.8 34.2 12.4 409 source: line-tlc red port 03:24 14.8* 3.30* 9.7* 29.3* 89 29.5 33.3 12.6 420 source: line-art 03:47 20.3* 3.42* 10.0* 30.2* 89 29.3 33.1 12.6 437 source: line-arterial 14:46 17.6* 3.62* 11.0* 31.1* 86 30.4 35.4* 12.5 455* source: line-left radial 03:48 17.1* 3.72* 11.0* 31.8* 86 29.7 34.7 12.5 479* source: line-art 05:53 16.9* 3.61* 10.8* 32.1* 89 30.0 33.7 11.9 400 added diff at 10:07am on 14:00 12.5* 3.56* 10.6* 30.5* 86 29.6 34.6 12.3 436 differential neuts bands lymphs monos eos baso atyps metas 04:46 61.8 23.7 10.1 3.7 0.6 source: line-cvp 03:48 72.0* 13.0* 13.9* 0.8 0.4 source: line-art 05:53 77.9* 8.5* 13.0* 0.3 0.3 added diff at 10:07am on 14:00 80.0* 10.2* 8.9 0.4 0.5 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 07:05 335 lab use only 07:05 chemistry renal & glucose glucose urean creat na k cl hco3 angap 07:05 961 21* 0.9 141 4.2 96 40* 9 07:55 151*1 23* 0.9 143 4.1 100 39* 8 08:00 185*1 37* 0.9 142 4.0 101 36* 9 06:27 198*1 61* 1.4* 140 4.3 102 32 10 21:00 141 4.6 104 19:00 139 6.1*2 103 moderately hemolyzed specimen 06:46 177*1 74* 2.4* 137 5.4* 100 31 11 08:00 159*1 68* 3.1* 137 5.2* 99 31 12 12:38 191*1 58* 3.7* 137 4.9 99 28 15 06:50 179*1 15 1.0 135 4.0 94* 37* 8 bnp added 11:57am 05:39 110*1 17 1.0 134 4.0 93* 38* 7* source: line-cvl 14:59 124*1 20 1.1 136 4.0 94* 38* 8 source: line-triple 04:46 144*1 20 1.0 137 4.6 92* 38* 12 source: line-cvp 22:57 132*1 22* 1.1 135 4.0 89* 41*3 9 source: line-central line 18:45 23* 1.1 136 4.5 88* 40* 13 06:45 144*1 16 1.0 134 4.7 87* 42*4 10 source: line-right ij central line 15:27 122*1 15 1.1 131* 4.1 86* 39* 10 source: line-rt cvl 02:13 * 4.2 86* 38* 11 source: line-central line 18:23 165*1 10 0.7 130* 4.7 87* 38* 10 source: line-arterial 04:45 125*1 11 0.8 127* 3.7 83* 36* 12 source: line-tlc red port 00:09 841 11 0.8 131* 4.0 86* 38* 11 source: line-tlc 16:18 164*1 12 0.8 131* 4.6 90* 36* 10 source: line-art 03:24 182*1 14 0.9 127* 3.7 88* 35* 8 source: line-art 23:45 150*1 13 0.8 129* 3.9 91* 33* 9 source: line-art 15:29 139*1 15 0.9 129* 3.4 87* 37* 8 source: line-left radial 03:47 175*1 17 0.9 126* 4.2 90* 33* 7* source: line-arterial 20:48 185*5 18 0.9 126* 3.3 87* 33* 9 source: line-arterial 14:46 119*1 17 0.6 129* 3.3 91* 34* 7* source: line-left radial 03:48 127*1 21* 0.8 120*6 4.67 85*7 31 9 source: line-art 23:53 981 23* 0.8 120*8 3.89 86*9 29 9 source: line-art 21:00 104*1 23* 0.9 119*10 3.9 85* 28 10 source: line-art 15:07 69*1 23* 0.7 119*11 4.1 85* 26 12 source: line-tlc 11:37 46*12 24* 0.7 120*13 4.4 88* 26 10 source: line-art 05:53 146*1 25* 0.7 113*14 5.6* 84* 22 13 01:36 0.7 111*15 5.5* 82* 22:00 0.6 109*16 5.2* 81* added , fe, tibc @ 2320 17:04 144*1 25* 0.7 110*17 5.1 74*18 31 10 added osmo @ 2031 14:00 228*1 27* 0.7 106*19 6.8*20 73*19 23 17 added chem 6 and glur; grossly hemolyzed specimen if fasting, 70-100 normal, >125 provisional diabetes hemolysis falsely elevates k using this patient's age, gender, and serum creatinine value of 1.4, estimated gfr = 36 if non african-american (ml/min/1.73 m2) estimated gfr = 43 if african-american (ml/min/1.73 m2) for comparison, mean gfr for age group 70+ is 75 (ml/min/1.73 m2) gfr<60 = chronic kidney disease, gfr<15 = kidney failure enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 12:38 20 28 34* 0.2 06:50 26 22 851 44 0.3 bnp added 11:57am 22:57 28 29 41 0.2 source: line-central line 04:45 26 20 53 0.7 source: line-tlc red port 03:47 41* 22 55 0.4 source: line-arterial 03:48 57* 39 63 0.3 source: line-art 15:07 260*1 source: line-tlc 05:53 67* 60* 406*1 01:36 454*1 22:00 364*1 added , fe, tibc @ 2320 14:00 72*2 109*3 66 0.4 added chem 6 and glur; grossly hemolyzed specimen . new reference interval as of ;upper limit (97.5th %ile) varies with ancestry and gender (male/female);whites 322/201 blacks 801/414 asians 641/313 hemolysis falsely elevates alt hemolysis falsely elevates ast. other enzymes & bilirubins lipase 14:00 31 added chem 6 and glur; grossly hemolyzed specimen cpk isoenzymes ck-mb mb indx ctropnt probnp 06:50 4 <0.*2 bnp added 11:57am 10:44 3 <0.011 source: line-right ij triple 22:57 3 0.02*3 source: line-central line 15:07 8 0.03*3 source: line-tlc 05:53 12* 3.0 0.02*3 01:36 13* 2.9 0.02*3 14:00 0.02*3 added tnt @ 1505 14:00 *2 added chem 6 and glur; grossly hemolyzed specimen . <0.01 ctropnt > 0.10 ng/ml suggests acute mi reference values vary with age, sex, and renal function;at 35% prevalence, ntprobnp values; < 450 have 99% neg pred value; >1000 have 78% pos pred value;see online lab manual for more detailed information ctropnt > 0.10 ng/ml suggests acute mi chemistry totprot albumin globuln calcium phos mg uricacd iron 07:05 8.6 2.7 1.5* 07:55 8.7 2.1* 1.7 08:00 8.8 1.4* 2.0 06:27 8.3* 2.9 2.5 06:46 8.3* 4.9* 2.7* 08:00 8.7 6.2* 2.6 12:38 3.6 8.3* 6.8* 2.5 06:50 4.0 9.4 3.6 2.1 bnp added 11:57am 05:39 8.5 2.5* 2.3 source: line-cvl 14:59 8.5 3.3 2.4 source: line-triple 04:46 8.6 4.3 2.3 source: line-cvp 22:57 8.5 4.9* 2.3 source: line-central line 06:45 9.0 4.3 2.4 source: line-right ij central line 15:27 8.6 3.5 4.4* source: line-rt cvl 02:13 8.6 3.8 1.8 source: line-central line 18:23 7.9* 4.7* 2.0 source: line-arterial 04:45 3.2* 8.2* 3.4 2.8* source: line-tlc red port 00:09 8.0* 3.2 1.8 source: line-tlc 16:18 8.3* 3.5 1.9 source: line-art 03:24 7.6* 1.3* 2.3 source: line-art 15:29 8.1* 2.3* 1.9 source: line-left radial 03:47 2.6* 7.7* 1.9* 2.6 source: line-arterial 20:48 7.8* 2.5* 1.6 source: line-arterial 14:46 7.7* 2.3* 1.7 source: line-left radial 03:48 7.8* 1.8* 1.9 source: line-art 05:53 7.6* 4.0 2.1 22:00 55 added , fe, tibc @ 2320 hematologic caltibc ferritn trf 22:00 221* 293* 170* added , fe, tibc @ 2320 other chemistry osmolal 17:04 248*1 added osmo @ 2031 pituitary tsh 06:50 2.5 bnp added 11:57am antibiotics vanco 23:13 13.4 source: line-a-line; vancomycin @ 2300 lab use only ltgrnhd edta ho holdblu redhold 06:55 hold blood gas blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph caltco2 base xs intubat vent comment 10:16 art 295* 98*1 7.22*1 42*2 8 not intuba3 not intubated whole blood, miscellaneous chemistry glucose lactate na k 10:16 0.7 hemogloblin fractions ( cooximetry) o2 sat 06:01 87 calcium freeca 10:16 1.24 brief hospital course: 84 year-old female pmh dm, htn, h/o tuberculosis s/p treatment, hyperlipidemia who presents to the ed with abdominal pain, hematuria, hypoxemia, and hyponatremia on arrival. she had a complicated hospital course, with new diagnoses of diastolic heart failure and atrial fibrillation, summarized below: . pulmonary: (hypoxemia and hypercarbia). pt hypoxemia was originally thought to be due to a pneumonia seen on cxr. she was initially treated with ceftriaxone and azithromycin, but her respiratory distress continued with worsening hypoxemia and hypercarbia. she then was transferred to the icu on and intubated. she was found to be in flash volume overload (not seen previously on cxr) with pleural effusions. tte showed preserved ef but with elongated left atrium and 1+ mr. she was diagnosed with diastolic heart failure and diuresed with lasix gtt. she extubated on with good respiratory status and was thereafter transferred back to floor. soon after that, she was noted to be somnolent and was again sent to the icu on for hypercarbic respiratory arrest. she did not require intubation or bipap this time and improved shortly. on closer examination of her labs, it appears that she has chronic respiratory acidosis of unknown etiology, possibly worsened by concomitant acetazolamide, later discontinued. she was again transferred to the floor on , but on she was noted to have labored breathing and hypoxia, necessitating retransfer to the icu. unclear explanation for likely chronic hypoxia with compensatory metabolic alkalosis. ?old scarring from prior tuberculosis infection/osa?. if within goals of care, pt can arrange outpatient sleep study and pulmonary evaluation. pt was discharged on 2l o2 nc. pt can pursue pulmonary and/or cardiac workup as determined by her goals of care. ct has suggested centrilobular nodules, fibrotic changes, tracheobronchomalacia, pleural effusion. this may explain hypoxia and can be pursued as outpatient if indicated. . again transferred to on , where she was attempted to be diuresed, but didn't respond and became anuric x 24 h, and hypotensive with sbp in 50s. she was then made cmo, but her vs and mental status suddenly improved. per pt family request, her cmo was reversed, and ivf were started. she has suffered likely atn in the meantime, with cr 3.8. . # goals of care. on initial admission patient full code. patient with protracted hospitalization with several re-admissions to the icu due to hypercarbic respiratory failure that failed to respond to further diuresis or non-invasive breathing support. prior to third icu transfer, extensive family discussion changed code status to dnr/dni. later, when she became hypotensive and anuric on , she was made cmo. this was reversed when her bp and mental status improved. after this, she and her family wanted minimal intervention pending 2-3 days to determine whether she will recover from her atn (e.g., 1. no vital signs at night, 2. no finger sticks, 3. no telemetry, 4. no drugs except for atenolol 5. temporary daily labs to determine renal function). while on the medical floor, pt's creatinine improved daily. as above, initially family did not want vital signs, labs or monitoring of the patient, but as her status improved, they began to allow labs, finger sticks and vital signs. however, it has been very difficult to treat the patient for her afib with intermittent rvr and recent chf. many family meetings and discussions were held. however, given last icu stay, family believes that medications are what lead to the patient needing icu care and almost dying. family would like little interventions and to take the patient home. however, they no longer wanted hospice care. explained to the family that patient has 2 conditions, afib/chf that are not being treated according to standards of care. family has been deciding what meds and at what dose to give the patient and treating these conditions has been difficult. situation has been delicate as family no longer wanting hospice level of care, but also not wanting full treatments. pt family would like to take the patient home with vna/pt and they stated they will provide 24 hr care and supervision. they are aware that pt's afib is not currently adequately managed and pt is still requiring oxygen. they would like to take her home with 02. explained to family that ideally would like to optimize the patient prior to dc so that readmission would not occur soon. however, family occasionally continued to decide on doses and type of medications.. therefore, pt's family would like to take her home with the above services in place and pcp follow up. . # hypoxia: likely multifactorial. initially attributed to bilateral effusions and possible pneumonia. she was started on treatment for cap for ceftriaxone and azithromycin. legionella negative. she spiked fever to 101 and broadened to vancomycin for sputum culture with gpc's. she was continued on antibiotics until - at that time they were discontinued due to low clinical suspicion for ongoing infection. blood cx ngtd. bilateral effusions and cardiomegaly on cxr suggestive of chf. after receiving fluids for treatment of hyponatremia (initially presumed hypovolemia hyponatremia) patient went into pulmonary edema. worsening hypoxia and respiratory failure culminated in intubation. interesting tte with preserved systolic function, normal right ventricular chamber size and wall motion; mild mr and small pericardial effusion. patient was actively diuresised with lasix ggt. patient successfully extubated on . lasix ggt was transitioned to 20mg iv lasix bolus on . los ~ - 7l on diuretic. she was continued on lasix 20mg iv until decision to transition care to minimal interventions. after last icu stay, pt's family extremely reluctant to allow diuretic medication to be used. pt not discharged on lasix. in addition, likely that pt has a chronic respiratory acidosis and chronic hypoxia perhaps related to prior infection with tuberculosis. . #pleural effusions-as above. likely related to chf. improved on subsequent imaging. if reoccur, can consider thoracentesis and pulmonary follow up. . # hyponatremia: on admission patient found to be profoundly hyponatremic at 106. hctz was discontinued. initial exam and laboratory data with urine na < 10 was suggestive of hypovolemic hyponatremia. she was initially started ns 175 cc/hr. na was monitored every 4 hours with goal correction no more than 12 meq in 24 hours (0.5meq/hr). there was no change in mental status therefore no current indication for hypertonic saline. patient received ns x1 day with sodium gradually correcting. patient became hypoxic after administration of ~3l of ivf. bnp: 10,000. she was then actively diuresised for treatment of her hyponatremia. labs were monitored and na corrected and stabilized. . # episode of somulence. patient called out of the icu on . on the afternoon of experienced episode of increasingly somulence. at that time vital signs were stable, labs without sign of electrolyte abnormal and glucose within normal limit. abg demonstrated a co2: 75. patient was readmitted to the icu due to concern for hypercarbia. transferred to , where she did well without need for intubation. she remained hypercarbic, and it was thought that her respiratory status was chronic respiratory acidosis with appropriate metabolic compensation, possible new metabolic alkalosis given diuresis, and possible acute component. she was written for nasal bipap but did well before this was administered. no other events while in . did not reoccur after last icu stay. . # abdominal pain: on admission patient with complaint of diffuse abd pain however no complaints during admission. abdominal exam notable for mild distension however ct scan without obstruction or acute abnormality. lactate was normal. pt given simethicone for gas with good effect. lfts normal. . #metabolic alkalosis: thought to be compensatory from chronic metabolic acidosis. also likely acute worsened by diuresis. can be followed in the outpatient setting. . # hematuria: admission ua + blood but no rbc. repeat ua + rbc, negative for myoglogin and serum ck of 406. ua negative for signs of infection. urine cx without growth. pt should have work up for hematuria in the outpatient setting. . # history of tuberculosis. according to history patient completed adequate tuberculosis therapy in at . admission ct scan with widespread centrilobular nodules in a tree-in- distribution in the right lung, with possible small cavitating nodules in the right lower lobe which is compatible with a small airways infectious process as well as endobronchial spread of tuberculosis. imaging reviewed, findings deemed consistent with treated tuberculosis. . # hypotension: patient with labile pressures in house. episodes of rapid atrial fibrillation necessiated use of phenyleprine intermittently. . # atrial fibrillation: chads2: 4. rate intermittently difficult to control in house. started on amiodarone bolus + gtt. transitioned to po metoprolol after extubation and uptitrated to 37.5mg q8hrs. started on lovenox for anticoagulation bridge to warfarin. her outpt cardiologist, dr. , was contact and confirmed that she was on plavix for h/o carotid disease; plavix was d/c'd. after her 3rd icu stay and goc discussion, it was decided by family to d/c all warfarin and lovenox. afib has been difficult to control as pt's family reluctant to allow certain medications. however, family allowed diltiazem dosing as prior to admission and low doses of metoprolol. pt discharged on same dose of dilt prior to admit and also atenolol was changed to metoprolol given renal function. family does not want anticoagulation and this may be a wise choice as pt also fell during admission. . # hyperlipidemia: continued lipitor, but later declined by family per goc discussion. family, allowed this medication to be resumed. . # dm: held oral glycemics. hiss initially while in house, but family later declined this. restarted glyburide at 2.5mg from 5mg . however, given relatively decreased po and renal function and goals of care, decided to dc oral hypoglycemics. instructed pt to have vna check finger sticks and if sugars elevated, can consider starting glipizide as an outpatient. . #normocytic anemia-no signs of active bleeding. likely do to repeat phlebotomy and acute illness. has remained relatively stable. iron studies consistent with chronic disease. stable during admission. can consider colonoscopy if indicated in outpatient setting. . #radiographic findings that may require follow up: centrilobular nodules r.lung compatible with small airways infections process, fibrotic changes r.lung apex, 2cm left upper lobe subpleural opacity, tracheobronchomalacia, pleural effusions, l1 compression fracture, gallbladder edema. medications on admission: confirmed with pcp and cardiologist: atenolol 50 mg tablet one tablet(s) by mouth every night at bedtime lipitor 20 mg qhs plavix 75 mg qd glyburide 3 mg lisinopril 30 mg qd diltiazem cd 120 mg diazepam 5 prn discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). disp:*30 adhesive patch, medicated(s)* refills:*0* 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. home oxygen 2l of continuous oxygen therapy. 4. hospital bed electric adjustable hospital bed. 5. diltiazem hcl 120 mg capsule,degradable cnt release sig: one (1) capsule,degradable cnt release po once a day. 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gas. disp:*30 tablet, chewable(s)* refills:*0* 8. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*1* discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis: congestive heart failure, hypervolemic hyponatremia, atrial fibrillation with rapid venticular response, shock, acute kidney injury due to acute tubular nephrosis, hypercarbic respiratory failure, metabolic alkalosis secondary diagnosis: type 2 diabetes, hypertension, peripheral vascular disease discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you have been admitted with respiratory failure likely due to underlying lung disease, heart failure, and atrial fibrillation. you have had a complicated hospital stay that has included treatment for these diagnoses, as well as low blood pressure and kidney failure. after your stay in the icu, your kidney function improved. after multiple discussions with your family, it was decided that you wanted to return to your home. you and your family are aware that you have atrial fibrillation and other conditions that are not being aggressively managed at this time. you will be discharged with home visiting nurses, oxygen therapy, physical therapy and 24 hour supervision. . your glyburide was stopped as your renal function is impaired and your blood sugar has been ok. your family also did not want finger sticks or too many medications. please discuss with dr. if/when you should resume this medication. . the following changes were made to your medication regimen: 1.your family has stopped your plavix and does not want coumadin. 2.your glyburide was stopped as your family did not want finger sticks and your kidney function is slightly impaired. 3.your lisinopril was decreased to 10mg daily 4.your atenolol was changed to metoprolol given your kidney function. 5.you were started on simethicone for abdominal gas 6.you were given a lidocaine patch for pain related to your pressure sore. followup instructions: please attend the following appointments: name: , address: , , phone: *please call dr. to schedule an appointment within one week. the office has been closed due to the weather.* procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances diagnoses: pneumonia, organism unspecified hyperpotassemia anemia, unspecified acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia atrial fibrillation other and unspecified hyperlipidemia acute respiratory failure other shock without mention of trauma osteoporosis, unspecified retention of urine, unspecified do not resuscitate status gross hematuria acute diastolic heart failure other diseases of trachea and bronchus mixed acid-base balance disorder personal history of tuberculosis physical restraints status 

Answer: The patient is high likely exposed to