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: s/p cardiac arrest major surgical or invasive procedure: endotracheal intubation cardiac catheterization with placement of drug eluding stent to mid-lad placement right pigtail catheter in pleural space placement right picc line placement right chest tube icd placement history of present illness: mr. is a 57 yo male found down on side of road with abrasions to the face. per wife, they had just bought a bicycle and the patient was riding it home with the wife driving ahead in a car. she said he was not traveling at a particularly fast pace, but she got ahead of him and proceeded home. the next she heard he had been found down on the wrong side of the road. per wife, pt was an avid biker prior to his mi in and would not have ridden on the wrong side of the road, so something must have happened to cause him to swerve that way. the patient was found down, apneic and without a pulse. he was defibrillated x3, received cpr, epi/vaso, and intubated in the field. in the ed, he was evaluated by trauma surgery, pan-ct, rib fractures and pulmonary contusions but no obvious active hemorrhage. the patient was noted to have a flail chest, presumably from ?cpr vs. trauma. the patient was noted to have st depressions inferiorly. the patient was initiated on a cooling regimen, getting cisatracurium, versed, fentanyl. in the ed, bps 130s/80s, hr-70s-80s. unable to obtain review fo symptoms as pt was intubated and unresponsive. per wife, pt had not had any anginal symptoms prior to this event. no chest pain or shortness of breath recently, and she reports that this is something he would report to her if it occurred. he had only just begun biking again. he has a history of stent placement to the lad in at . at that time, he presented with restrosternal chest pain with exertion x 2, the second episode persistent, leading to ed presentation. found to have nstemi with positive biomarkers. she said that he is very organized with medications and always takes them as directed, and has not missed doses. past medical history: 1. cardiac risk factors: + diabetes, + dyslipidemia, + hypertension 2. cardiac history: - percutaneous coronary interventions: - to proximal lad () - hospitalized for atypical chest pain () 3. other past medical history: - spontaneous pneumothorax while biking (date unknown) - toe amputation for non-healing ulcer diabetes - diabetes mellitus type 2 on insulin, dx age 42, c/b peripheral neuropathy and proteinuria (baseline creatinine 0.9 in ) - htn - hld - h/o depression - erectile dysfuntion - fatty liver - tubular adenoma on colonoscopy social history: married, one daughter, two sons. former competitive rower and rowed for as undergrad. - tobacco history: nonsmoker - etoh: once a month family history: father - mi in mid-50s and cabg, died at age 69 from mi. physical exam: physical exam on admission: general: intubated, sedated, wearing cooling device. heent: intubated. neck: in neck brace. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. lungs: ctab anteriorly, but could not assess posterior or inferior lung sounds due to cooling device abdomen: in cooling device, could not assess. extremities: no edema, 2+ pulses ue and le bilat. skin: cool to touch. occ abrasions with denuded skin over le and ue bilat. neuro: sedated, unresponsive pulses: 2+ dp and radial physical exam on discharge: afebrile, bp 110-130s/70-80s, hr 80s, saturations >94% on ra awake, alert, interactive and appropriate. voice is shaky and quiet but no dysarthria. oriented x3 but waxes and wanes rrr, no m/r/g decreased breath sounds in the right base but no crackles or wheezes abdomen is soft, nontender, nondistended no edema, 2+ pulses bilateral dp and radial neuro exam: oriented x 3, cn 2-12 intact, strength right deltoids , left , bilateral forearms , bilateral hip flexers , bilateral plantarflexion . sensation intact to light touch in dermatomes c5-t1 an l4-s1. gait only with assistance pertinent results: admission labs: 03:10pm wbc-13.0* rbc-4.79 hgb-15.3 hct-45.2 mcv-94 mch-32.0 mchc-34.0 rdw-12.2 03:10pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:10pm albumin-4.2 calcium-9.0 phosphate-8.8* magnesium-2.6 03:10pm ctropnt-<0.01 03:10pm lipase-64* 03:10pm alt(sgpt)-1684* ast(sgot)-1113* alk phos-85 tot bili-2.0* 03:10pm urea n-26* creat-1.4* 03:15pm freeca-1.12 03:15pm glucose-259* lactate-13.6* na+-143 k+-3.7 cl--109* tco2-13* 05:25pm type-art rates- tidal vol-600 peep-5 o2-100 po2-208* pco2-40 ph-7.30* total co2-20* base xs--5 aado2-475 req o2-80 intubated-intubated 10:17pm ck-mb-34* mb indx-4.1 ctropnt-0.97* 10:17pm glucose-294* urea n-25* creat-1.2 sodium-138 potassium-6.4* chloride-105 total co2-14* anion gap-25* . imaging: ct head non-contrast (): there is no evidence of acute intracranial hemorrhage, mass effect, or shift of normally midline structures. there is no cerebral edema or loss of -white matter differentiation to suggest an acute ischemic event. the sulci and ventricles are slightly prominent, likely age related involutional changes. there is no hydrocephalus. the basal cisterns are patent. imaged paranasal sinuses and mastoid air cells appear well aerated. no acute fracture is seen. impression: no evidence of acute intracranial process. . ct c-spine (): there is no evidence of acute cervical spine fracture or malalignment. a non-displaced fracture of the right first rib is noted. no significant degenerative changes are seen including no evidence of critical central canal stenosis. evaluation of the prevertebral soft tissues is limited due to endotracheal and orogastric tube placement. ground-glass opacities in the imaged lung apices are better assessed on ct torso of the same date. impression: no evidence of acute cervical spine fracture or malalignment. non-displaced fracture of the right first rib. . ct torso (): 1. right upper and middle lobe ground-glass opacities, most likely representing areas of contusion and aspiration. bilateral lower lobe consolidations, which may reflect atelectasis or aspiration. 2. multiple bilateral rib fractures, including displaced right anterior rib fractures, likely related to recent cpr. no pneumothorax. 3. severe coronary artery calcifications. 4. decreased liver attenuation, possibly suggestive of fatty deposition. . cxr (): there is an endotracheal tube and a feeding tube whose distal tip is not well seen. there is unchanged stable cardiomegaly. there are multiple right-sided rib fractures. there are areas of increased density within the right lung, possibly due to contusion related to the rib fractures. no pneumothoraces are seen. . records: c. cath : findings: - lm patent. lad 95% proximal stenosis with 40-50% stenoses in mid-, distal-, and diags. lcx 40% prox stenosis, rca 40% mid vessel dz. intervention: - pta and des to proximal lad. . routine follow up exercise stress test s/p mi : 1-1.5mm horizontal st segment depressions in leads v5-v6 at peak exercise which became rapidly upsloping by one minute following cessation of exercise. quickly resolved. asymptomatic. walked 12 minutes; excellent exercise tolerance. obtained nuclear stress above ekg findings --> no ischemia but multiple pvcs, pvc couplets, and pvc triplets causing termination of test. arrythmia resolved with rest. . diagnostic c. cath (right heart) (done nsvt on stress test): left dominant heart. left main normal. lad with widely patent stent. 40-50% stenoses at mid and distal lad. lcx normal. rca normal. . exercise stress test/mr spect for atypical cp: excellent exercise capacity (15 mets). exercise time 13 minutes. hr 60 --> 146 (88% of predicted). bp 118/68 --> 160/80. no chest pain. end point: dypsnea, fatigue. occasional apcs and vpcs on ekg but neg for ischemia. nsvt. myocardial perfusion images normal without evidence of ischemia or infarction. lvef 62% with normal contractile function. . peripheral arterial testing : no pad in right or left leg. . echo : right atrium/interatrial septum: normal ra size. left ventricle: mild symmetric lvh with normal cavity size. severe regional lv systolic dysfunction. severely depressed lvef. no lv mass/thrombus. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. aortic valve: normal aortic valve leaflets (3). no ar. mitral valve: mild to moderate (+) mr. tricuspid valve: mild tr. borderline pa systolic hypertension. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor subcostal views. suboptimal image quality - ventilator. conclusions there is mild symmetric left ventricular hypertrophy with normal cavity size. there is severe regional left ventricular systolic dysfunction with akinesis of the anterior wall, septum and distal inferior wall. the apex is dyskinetic. the remaining segments contract normally (lvef = 25-30%). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. impression: severe regional left ventricular systolic dysfunction, c/w extensive lad-territory infarction. dyskinetic lv apex without current evidence of thrombus. mild to moderate mitral regurgitation. . cardiac cath : findings estimated blood loss: <30 cc hemodynamics (see above): coronary angiography: left dominant lmca: no angiographically apparent cad lad: proximal calcification. mid vessel diffuse 80-90% stenosis lcx: mild luminal irregularities rca: nondominant. mild luminal irregularities interventional details change for 6 french xblad3.5. crossed with prowater wire and predilated with a 2.5 mm balloon. could not cross with a stent. further predilation and then able to deliver a 3.0 x 30 mm resolute stent. postdilated with a 3.5 mm balloon. final angiography revealed normal flow, no dissection and 0% residual stenosis. . cta chest : technique: mdct-acquired axial images were obtained from the thoracic inlet to the pubic symphysis prior to and following the uneventful administration of 120 cc omnipaque intravenous contrast. coronally and sagittally reformatted images were generated and reviewed. ct chest with contrast: the pulmonary arterial tree is well opacified with intravenous contrast to the subsegmental levels without filling defects to suggest pulmonary embolism. the pulmonary arterial trunk is normal in caliber. the thoracic aorta is also normal in caliber without evidence of acute aortic syndrome. there is a left-sided central venous catheter in place with the tip terminating in the svc. there is a normal three-vessel takeoff from the aortic arch. the great vessels are otherwise unremarkable. the heart is normal in size without pericardial effusion. there are dense calcifications of the coronary arteries. no pathologically enlarged axillary, mediastinal, or hilar lymph nodes are detected. the tracheobronchial tree is patent to the subsegmental levels. an endotracheal tube appears appropriately positioned. an orogastric tube is also seen coursing through the esophagus and terminating in the stomach. the thyroid gland is unremarkable. there is a moderate-sized right pneumothorax which is new from . a right-sided chest tube is in place with the tip terminating posterior to be lung which is inadequately positioned. within the pulmonary parenchyma, there are diffuse nodular and tree-in- opacities predominantly in the right lung with more confluent regions of consolidation in the right lung base and left lung base. no pleural effusions are present. . ct of the abdomen with contrast: the liver enhances homogeneously without evidence of hepatic laceration. no focal liver lesion is identified. no intrahepatic or extrahepatic biliary ductal dilation is seen. the gallbladder contains dense material layering in the dependent portions consistent with vicarious excretion of contrast from prior ct. no calcified gallstones are seen and there is no gallbladder wall edema or pericholecystic fluid to suggest acute inflammation. the spleen is unremarkable. two splenules are incidentally noted at the splenic hilum. the pancreas, bilateral adrenal glands, and kidneys are unremarkable. the intra-abdominal loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. there is no free air or ascites. no pathologically enlarged lymph nodes are identified in the retroperitoneal or mesenteric regions. the intra-abdominal aorta and its branches are normal in caliber and patent. ct of the pelvis with contrast: the urinary bladder is relatively decompressed by a foley catheter in place. loculated gas is again seen in the dome of the bladder likely related to foley placement. the rectum, prostate, seminal vesicles and sigmoid colon are unremarkable. there is no free pelvic fluid/inguinal or pelvic lymphadenopathy. a small fat-containing left inguinal hernia is incidentally noted. osseous structures: there are multiple displaced fractures involving the right anterior second, third, fourth, fifth and a minimally displaced fracture involving the right anterolateral sixth rib. there are fractures at the right costochondral cartilage at the levels of the right second, third, fourth, and fifth ribs. nondisplaced fractures are seen involving the right posterior fifth, sixth and seventh ribs. the spine appears intact. subcutaneous air is seen in the right thorax and overlying the sternum. impression: 1. moderate-sized right pneumothorax is new from with a posteriorly positioned right chest tube which is not adequately draining the pneumothorax. 2. bibasilar pulmonary consolidations and nodular and confluent opacities in the right lung most likely represent areas of aspiration/atelectasis and contusion, respectively. 3. multiple rib fractures and fractures of the right costochondral cartilage. 4. severe coronary artery calcifications. no evidence of acute aortic injury or acute intra-abdominal pathology. . ct chest : findings: a previously large pneumothorax, barely visible on chest radiograph, is tiny. minimal residual air is seen in the right lung base (401b:14) adjacent to the right atrium (401b:21). multifocal consolidations in the right middle lobe have coalesced to a larger consolidation with air bronchograms (2:40). the right lower lobe remains completely collapsed. the left lower lobe is completely collapsed, whereas previously the superior segment of the left lower lobe remained aerated. ground-glass opacity in the posterior right upper lobe (2:36) has coalesced into a small consolidation. small amount of pneumomediastinum is similar. coronary artery calcifications in the lad and proximal circumflex are similar. the heart is mildly enlarged. the great vessels are normal caliber. the aortic arch is free of calcifications. a left-sided picc line tip terminates in the low svc. an enteric catheter courses into the stomach. this study was not designed to evaluate sub-diaphragmatic contents. the hypodense liver is consistent with diffuse steatosis. a 2 cm cc x 4.3 cm tv hyperdense lesion at the left liver capsular edge (401b:25) was hypodense on the portal venous phase of prior imaging studies. a smaller 3.2 cm tv x 1.2 cm cc similarly hyperattenuating lesion is located along the superior liver edge in segment ii (401b:25). displaced overriding rib fractures of the anterior right 2nd through fifth ribs are unchanged. there are no lytic or sclerotic bone lesions concering for malignancy. impression: 1. tiny residual right pnuemothorax has improved 2. progressive bilateral lower lobe collapse 3. worsening right middle and left upper lobe pneumonia 4. fatty liver with two large hyperdense lesions in the left lobe which are more conspicuous on the present study. these lesions are non-specific and could represent benign or malignent entities. an abdominal mri is required for further characterization when the patient's acute issues have stabalized. . ct head : findings: there is no hemorrhage, edema, mass effect, or territorial infarction. the ventricles and sulci are normal in size and configuration. the basal cisterns remain patent and there is no evidence of central herniation. the -white matter differentiation is unchanged. there is mild mucosal thickening and there is an air-fluid level in the right maxillary and sphenoid sinuses, likely related to intubation. the mastoid air cells and middle ear cavities are clear. impression: no acute intracranial process. mri is more sensitive for evidence of anoxic brain injury. . ruq ultrasound : findings: the liver is normal in shape and contour. there is no increased echogenicity. in the left lobe of the liver, there is a small 1.5 x 1.5 cm hypoechoic lesion which does not have a corresponding lesion seen in the prior cts. there is no increased vascularity. the portal vein is patent. the gallbladder is unremarkable without evidence of cholelithiasis. mild echogenicity within the gallbladder likely represents artifact, or less likely a small amount of sludge. there is no gallbladder wall edema or pericholecystic fluid. the common bile duct measures 4 mm. there is no intra- or extra-hepatic biliary duct dilation. there is no ascites. impression: 1. no evidence of cholelithiasis or cholecystitis. hazy echogenicity within the gallbladder is likely artifact, although a small amount of sludge may be present. 2. indeterminate lesion in the left lobe of the liver. recommend nonemergent followup with mri for further evaluation. . ct chest/abdomen/pelvis: ct chest: the thyroid gland contains an 8-mm hypodense lesion in the inferior left lobe (2:13). no axillary or supraclavicular lymphadenopathy is seen. shotty lymph nodes in the mediastinum do not meet ct size criteria for lymphadenopathy. an endotracheal tube is in place with the tip terminating at the level of the clavicles. an orogastric tube is in place. a left-sided picc line is seen with the tip terminating in the low svc. the pulmonary arterial trunk is normal in caliber as is the thoracic aorta. there is a normal three-vessel takeoff from the aortic arch. the heart is normal in size without pericardial effusion. calcification of the coronary arteries is noted with a possible stent in the left anterior descending artery. the central tracheobronchial tree is patent to the subsegmental levels. there are no pleural effusions. there is a recurrent small right pneumothorax with air seen in the cardiophrenic recess and the base of the right lung (2:43, 48) with slight leftward shift of the mediastinal structures. multifocal consolidations have coalesced to predominantly bibasilar consolidations with air bronchograms (2:43). there is residual ground-glass opacification in the right upper lobe (2:30). a right-sided chest tube is unchanged in position, extending through the fissure with the tip terminating in the right lung apex. there is extensive subcutaneous emphysema extending through the soft tissues of the right thorax and also the right posterior neck. ct abdomen: evaluation of solid organs is limited without intravenous contrast. within these limitations, the liver is diffusely hypoattenuating consistent with hepatic steatosis. no gross liver abnormality is detected. no intra- or extra-hepatic biliary ductal dilatation is seen. the gallbladder contains diffuse hyperdensity consistent with biliary sludge. a solitary coarse calcification is noted in the head of the pancreas which is otherwise unremarkable. the spleen, bilateral adrenal glands and kidneys are unremarkable. two splenules measuring 1.9 cm and 2.9 cm are incidentally noted in the splenic hilum. an enteric feeding tube is in place within the stomach. the stomach and intra-abdominal loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. no free air or ascites is present. there is no appreciable mesenteric or retroperitoneal lymphadenopathy. the abdominal aorta is normal in caliber with minimal atherosclerosis. ct pelvis: the prostate and seminal vesicles are unremarkable. the urinary bladder is decompressed by a foley catheter with a locule of air in the nondependent portion of the bladder dome consistent with foley placement. the rectum and sigmoid colon are mildly distended with stool but otherwise unremarkable. there is no free pelvic fluid or inguinal/pelvic lymphadenopathy. osseous structures: no suspicious lytic or sclerotic lesions are detected. minimal degenerative changes are noted in the lumbar spine, most pronounced at the l2-3 level with loss of intervertebral disc space, endplate sclerosis and osteophytosis. displaced overriding rib fractures of the anterior right 2nd-5th ribs are unchanged. impression: 1. recurrent small right pneumothorax with slight leftward deviation of mediastinal structures from . 2. improved multifocal pneumonia with persistent bibasilar consolidation likely due to lower lobe collapse. 3. persisting ground-glass opacity in the right upper lobe. 4. hepatic steatosis. 5. hyperdense gallbladder consistent with biliary sludge. 6. no evidence of colitis or intra-abdominal abscess. . / mri head: findings: there is no acute intracranial hemorrhage, infarction, mass effect, or edema seen. ventricles and sulci appear age appropriate. major intracranial flow voids are preserved. there is fluid signal in the sphenoid sinuses, nasopharynx and mastoid air cells bilaterally, which might be related to intubation. visualized orbits appear unremarkable. impression: no acute intracranial abnormality. . mri cspine findings: limited examination due to patient motion. cervical vertebrae are normal in height, marrow signal intensity and alignment. craniocervical junction is normal. cervical spinal cord shows normal morphology and signal intensity. at c2-c3, uncovertebral and facet joint osteophytes result in moderate right neural foraminal narrowing. there is no significant spinal canal or left neural foraminal narrowing. at c3-c4, there is disc bulge effacing the anterior thecal sac remodeling the cord, but no cord signal abnormality is seen. there is no significant neural foraminal narrowing. at c4-c5 and c5-c6, there are disc bulges without significant canal or neural foraminal narrowing. at c6-c7, there is a disc bulge with central disc protrusion indenting the anterior thecal sac but no significant canal or neural foraminal narrowing is seen. at c7-t1, there is no significant spinal canal or neural foraminal narrowing. pre- and para-vertebral soft tissues appear unremarkable. impression: study limited by patient motion. mild degenerative changes in the cervical spine without significant spinal canal or neural foraminal narrowing. . emg: complex, abnormal study. there is electrophysiologic evidence for a generalized, sensorimotor polyneuropathy characterized by axonal loss, which is at least moderately severe. however, the complete absence of identifiable motor unit activity in upper and lower extremities with relatively normal motor nerve conduction studies is consistent with a primary upper motor neuron etiology for the patient's weakness. the associated finding of normal cranial emg supports a localization within the cervical spinal cord. there is no evidence for a presynaptic neuromuscular transmission disorder. . mri head and cspine: conclusion: hyperintense lesions in the medulla and upper cervical cord, not detectable on diffusion images. small right frontal white matter hyperintensity. these findings may all be a consequence of ischemia, but they do not appear acute by mr criteria. . tte: left atrium: normal la size. left ventricle: mild symmetric lvh with normal cavity size. mild regional lv systolic dysfunction. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with mid- and distal septal hypokinesis (mid-lad territory). the remaining segments contract normally (lvef = 40-45%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild regional left ventricular systolic dysfunction, c/w cad. mild pulmonary hypertension. . video swallow study findings: video swallow fluoroscopy was performed in conjunction with speech and swallow division. multiple consistencies of barium were administered. barium passed freely through the esophagus without evidence of obstruction. there was aspiration with thin and nectar consistencies, which improved on chin tuck. there was mild pharyngeal residue with pureed consistencies but no aspiration or penetration. impression: mild aspiration of thin and nectar consistencies which improved with chin tuck. pharyngeal residue with pureed consistency. please see speech and swallow note in omr for further details. brief hospital course: mr. is a 57 year old male with coronary artery disease (cad) status post stent to proximal lad in , hypertension, hyperlipidemia, and diabetes mellitus type 2 who was found down on side of road in ventricular fibrillation and cardiac arrest s/p resuscitation and intubation. he underwent cardiac cath with placement of des to mid-lad, and post-cath arctic sun cooling protocol. he had an icd placed before discharge for a primary vfib arrest. his course was complicated by rib fractures and resultant right pneumothorax requiring chest tube and ventilator-associated psuedomonas pneumonia. active issues: # primary vfib arrest: although he had a history of cad and is s/p drug eluding stent (des) to proximal left anterior descending (lad) in , he had been doing well prior to this incident. he was found down after riding a bike home, requiring multiple shocks for ventricular fibrillation (vf) arrest in the field and endotracheal intubation for respiratory failure. arctic sun cooling protocol was initiated in the ed on arrival. he was taken for cardiac cath and recieved des to mid-lad on . transferred to the ccu post-cath where he has been hemodynamically stable and cooled to 33'c. he was placed on neuromuscular blockade (cisatracurium) as well as fentanyl and versed. monitored on eeg for seizure activity while on nm block, no seizures seen. after 24 hours cooling was stopped and warming protocol initiated. nm block discontinued after patient reached 35'c per protocol. after rewarming, he remained became mildly hypertensive so he was restarted on home antihypertensives, which included metoprolol and lisinopril (takes captopril at home). he began to trend towards fevers (see below) so he was continued on artic sun device which kept him maintained at 37'c with cooling for an additional 48 hours. he was not extubatable after warming so tube feeds were initiated and he was transitioned to fentanyl/propofol. he was treated for mi with plavix 75mg daily, aspirin 325mg daily, atorvastatin 80 mg daily, metoprolol tartrate 25 mg . patient remained ventilator-dependent for 14 days. sedation was changed to precedex nearing extubatation. after additional management of his pneumothorax and pneumonia (see below) he was successfully extubated on without complication. there were many discussions about whether his vifb was secondary to acute mi or not, and ultimately it was felt that there was not evidence to confirm either way. since he may have had a primary vfib arrest (due to previous mi in and structural heart disease), he was a candidate for icd placement during this admission. he had an icd placed on and tolerated the procedure well. cxr the following day confirmed lead placement and interrogation by the ep team showed that it was functioning well. he should keep dressing on for three days, take keflex 500 mg 4x/d for 3 days, and follow-up in clinic. # pneumothorax: patient developed crepitus on exam the morning of hospital day 4 while still intubated. cxr revealed right apical pneumothorax and trauma surgery placed a pigtail catheter on . initially, this tube drained air and serosanguinous fluid and repeat cxr showed improvement in the pneumothorax. however, the following day his ventilator oxygenation requirements did not improve. he was requiring very high peep and fio2 90-100% to maintain saturations in the low to mid 90s. his blood pressures were also noted be decreased during this time. because the differential included pulmonary embolus and he was not clinically improving, a cta chest was performed on . this showed a large persistent right pneumothorax which was layered anteriorly and thus not visible on portable cxrs and the apical pigtail catheter was inadequately placed to drain. he also had basal pneumonia. trauma surgery returned and placed a right chest tube on with repeat ct chest the following day showing resolution of pneumothorax. he ventilator dependence and mild hypotension improved following chest tube placement. it was successfully removed on wihtouth recurrence of ptx. # ventilator associated pneumonia (vap): upon rewarming from the arctic sun protocol, the patient was noted to be persistently febrile. when he became hypoxic with increasing vent requirements, he was started on empiric coverage for vap in addition to treatment of pneumothorax as above. he remained febrile and sputum culture grew pseudomonas so ciprofloxacin was added to the regimen while awaiting sensitivities. pseudomonas was pan-sensitive so he was narrowed to ciprofloxacin only. however, he remained febrile so vanc and cefepime were added back on. flagyl was added to his regimen on for anaerobic coverage given fevers and concern for aspiration. vancomycin and ciprofloxacin were subsequently weaned off and he completed a 8 day course of cefepime and metronidazole from , which was the last day of positive sputum cultures. # mental status: initially we were unable to assess while pt was being cooled and sedated. though he was resuscitated, amount of time he was pulseless was unknown. patient had eeg performed early in his stay which showed mild/moderate diffuse background slowing and slow alpha rhythm, however was notable for background frequencies with the appearance of an anterior-posterior gradient of frequencies, clear reactivity, and improvement in the alpha rhythm frequency which was thought to be associated with good neurologic outcome. during daily attempts to wean off propofol, he was often noted to be agitated and somewhat delirious appearing. he was transitioned to precedex with apparent improvement in mental status and was extubated shortly thereafter. his mental status upon extubation was encouraging, with patient conversant and able to follow commands. he was noted to sundown intermittently with disorientation during his stay in the icu but was easily redirectable. to improve his sleep/wake cycle in the setting of sundowning, he was started on seroquel 25mg po qhs prn for insomnia and delirium. this was not continued to rehab but can be restarted if needed. # trauma: patient was admitted s/p fall from bike which may have resulted from or caused cardiac arrest. ct imaging showed no acute intracranial process but did show multiple rib fractures from cpr. his course was complicated by flail chest. he was followed by the trauma surgery team but they did not think he had any indications for surgery to fix the flail chest. chest tube placed on hospital day 4 as above for new onset pneumothorax. his c-spine was cleared with ct neck on admission and c-collar was removed per trauma surgery recommendations. # diabetes mellitus type 2: on insulin at home, complicated by peripheral neuropathy and proteinuria (baseline creatinine 0.9 in ). he required insulin drip while being cooled due to delayed absorption. transitioned to long-acting insulin plus ssi once pt was warmed. sugars again became difficult to control in the setting of continous tube feedings and infection. he again necessitated insulin drip before weaning to lantus with hiss. regimen on discharge included glargine 23 units at bedtime and a sliding scale insulin. this should be titrated based on qid fingersticks. # weakness: with weaning of sedation, it was noted patient was not moving extremities. head ct showed no acute process, and there was concern for critical illness neuropathy vs. myopathy. emg/ncs was ordered which was concerning for upper motor nerve lesion in the cervical spine. repeat mri's showed poorly defined subacute to chronic lesion in c1 to c2. regardless, patient's strength slowly returned and he was moving all extremities to command by day of extubation on . with continued pt he continued to improve and was able to move with assitance. he should continue with pt. # swallow discoordination: also, he had significant weakness of his pharyngeal muscles which cause quiet voice and swallowing difficulties. he had a video swallow and speech/swallow team evaluation which cleared him for a diet of pureed solids and honey-thick liquids. this can be advanced with time. # bladder atony: similarly, he had bladder atony after the foley was removed (in place 18-20 days) but eventually recovered his ability to urinate. if he cannot urinate, he may need a few straight caths while his bladder gets strength back. # hypertension (htn)/ hypotension: initially normotensive on admission to ed and ccu s/p cardiac arrest and resuscitation. held antihypertensives initially. his pressures decreased with sbp's in th 90's in the setting of new pneumothorax. antihypertensives including metoprolol and lisinopril were restarted when patients pressured had stabilized following treatment of ptx. on discharge his regimen consisted of lisinopril 10 mg daily, metoprolol succinate 100 mg daily. # hyperlipidemia (hld): he was taking simvastatin at home but was transitioned to high dose atorvastatin given his acute mi. discharged on atorvastatin 80 mg daily. his initial ck was very high 800s in the setting of being found down and trauma, ast/alt also very high (see below). both of these should be rechecked as an outpatient once he is stable to ensure that he is not having toxicity of high dose atorvastatin. # transaminitis: admission lfts very elevated with ast/alt 1100/1600, tbili 2.0, and normal alkaline phosphatase. it was felt that this pattern and history fit well with shock liver in the setting of cardiac arrest. also have lft elevation at baseline due to fatty liver disease. lft's trended down during admission and at the time of discharge were in the 80s. he should have these rechecked in a month or so and also should have a f/u mri of his liver for nondescript findings on ct. # h/o depression: not currently being treated for this, but has taken meds in the past. # erectile dysfunction (ed): on discharge, instruct pt to avoid ed meds. transitional issues: - for his icd: he should keep dressing on for three days and then leave his steri strips on until they fall off by themselves, take keflex 500 mg 4x/d for 3 days, and follow-up in clinic in one week. -follow-up needed for liver lesion seen on ultrasound- recommended a nonemergent mri to further characterize - recheck ck and ast/alt after stabilized as an outpatient to ensure no toxicity from high dose atorvastatin - to improve his sleep/wake cycle in the setting of sundowning, he was started on seroquel 25mg po qhs prn for insomnia and delirium. this was not continued to rehab but can be restarted if needed. medications on admission: - metoprolol succinate 12.5mg po daily - lisinopril 20mg daily - simvastatin 40mg po qhs - plavix 75mg po daily - insulin humalog ss + long acting insulin qhs (in he took lantus 25 units qhs) discharge medications: 1. aspirin 81 mg po daily 2. atorvastatin 80 mg po daily 3. clopidogrel 75 mg po daily 4. codeine sulfate 15-30 mg po hs:prn cough 5. lisinopril 10 mg po daily hold for sbp<100 6. metoprolol succinate xl 100 mg po daily hold for sbp<90 or hr<55 7. heparin 5000 unit sc tid discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses ventricular fibrillation coronary artery disease pneumothorax ventilator-associated pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were admitted to the hospital because you were found unresponsive, without a pulse and not breathing outside the hospital. the ems team performed cpr and they were able to get your heart pumping again. your lab work and ekg showed that you had a large heart attack. you underwent a cardiac cath with placement of a stent in your heart to open the artery and restore blood flow. you underwent cooling of your body in the icu to perserve your brain function while your heart had stopped pumping blood to the brain. you also were not breathing when the ems team found you alongside the road. you had a tube inserted in your lungs and you were ventilated by a machine in the icu. you had several rib fractures from the cpr and developed a pneumothorax. this is when free air enters the chest and pushes the lungs out of the way, collapsing the lungs. you had a tube inserted through your chest wall to let this air out so that the lungs could re-expand. while you were on the ventilator, you aspirated some of your saliva and vomit, resulting in a pneumonia. you recieved antibiotics for this and your respiratory status has improved. ultimately, you were in the icu under sedation for a very long time while your lungs were recovering. you are ready for discharge from the hospital now but you will still feel weak and tired for some time. you were paralyzed during part of this recovery and your body is using many of its resources to heal. this results in significant weakness and fatigue which can last for several months but which will get better as your work with physical therapy. the following changes were made to your medications: - change to metoprolol succinate 100 mg daily for your heart - stop taking simvastatin, this has been replaced with another med - start taking atorvastatin (lipitor) 80 mg daily for your cholesterol - start taking aspirin 81 mg daily for your heart - you should continue taking plavix 75 mg daily, this is to keep the stent in your heart open - decrease lisinopril to 10 mg daily - increase insulin as directed by the sliding scale you should keep all of the follow-up appointments listed below so that we can ensure that you continue to improve. you should bring your medications to each appointment so your doctors update their records and adjust the doses as needed. it was a pleasure taking care of you in the hospital! follow up needed for: you will need to have an mri of your liver to assess an area that they noticed on an ultrasound that would need to be further defined. followup instructions: while you are at , the doctor there will adjust your medications as needed. when you leave, they will arrange for an appointment with your primary care doctor: name: , m. location: primary care of address: , welleslley, phone: fax: name: , s. md location: cardiologists address: /ste. 562, , phone: appointment: thursday 1:00pm department: cardiac services when: monday at 9:00 am with: device clinic building: sc clinical ctr campus: east best parking: garage ** you will also have the cardiologists calling you to set up an appointment with dr. . procedure: insertion of intercostal catheter for drainage insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung left heart cardiac catheterization other and unspecified coronary arteriography enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus implantation or replacement of automatic cardioverter/defibrillator, total system [aicd] insertion of drug-eluting coronary artery stent(s) cranial or peripheral nerve graft insertion of one vascular stent excision of lingual thyroid percutaneous transluminal coronary angioplasty [ptca] procedure on single vessel diagnoses: acidosis coronary atherosclerosis of native coronary artery unspecified essential hypertension acute and subacute necrosis of liver acute kidney failure, unspecified diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes percutaneous transluminal coronary angioplasty status other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure cardiac arrest cardiogenic shock long-term (current) use of insulin old myocardial infarction ventricular fibrillation hyperosmolality and/or hypernatremia ventilator associated pneumonia accidents occurring in residential institution precipitous drop in hematocrit contusion of lung without mention of open wound into thorax flail chest other alteration of consciousness pseudomonas infection in conditions classified elsewhere and of unspecified site impotence of organic origin other pneumothorax 

Answer: The patient is high likely exposed to