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: left leg/foot infection major surgical or invasive procedure: : emergent left guillotine below-knee amputation. : closure of left guillotine below knee amputation : egd history of present illness: 73m, with pmh wegener's s/p renal transplant on prograf and r bka secondary to trauma, who was admitted to with septic shock secondary to left lower extremity cellulitis and serratia bacteremia, now transferred to for further management and revision of his av fistula. . briefly, the patient injured his left lower extremity on by "kicking a stick," developed increased pain/swelling/erythema and a fever of 102 overnight, and was then brought to where he was diagnosed with cellulitis. after admission, the patient dveloped septic shock with multiorgan system failure and transferred to the icu. wound and blood cultures subsequently returned positive for serratia marescens. in the icu, he was anuric, with liver dysfunction and "severe respiratory limitations." for his infection, he was started on broad-spectrum antibiotics (ceftaz and levo), and his left foot was surgically debrided, leaving a yellow eschar, with silvadone dressing done afterwards. for his shock, he required norepinephrine and vasopressin that were started on and stopped on . on , the patient developed afib with rvr, was treated with amiodarone drip until , after which he went in and out of afib at a rate of 74-75 on metoprolol. for his anuria, he was dialyzed on and via a pre-existing lue av fistula. during his last dialysis on , 600cc were taken off, and k of 2.4 was corrected with a 4.0 bath. afterwards, he had uop 20-30 cc/hr by foley, bun 85 and cr 3.2. for hypoxemia, he was placed on a bipap mask, and non-invasive ventilation was complicated by stage ii ulcer on the bridge of his nose. icu course was also complicated by metabolic acidosis, toxic metabolic encephalopathy with global weakness, and thrombocytopenia. . of note, the patient has been off pressors since , and off amiodarone since . his last hemodialysis was on the morning of . additionally, left lower extremity abi's showed: calf 1.09, ankle (pt) 0.91, ankle (dp) 0.84, digit 0.97. cr trend at sturdy included 0.95 (on admission) with peak of 4.95 upon starting dialysis on . subsequently, cr decreased to 3.2. bun was 29 on admission, peaked at 87 and was 85 on transfer. wbc peaked at 23.5 and were 11.2 on transfer. platelets had dropped from 119 on admission, to a nadir of 56, and were 70 at the time of discharge. last tacrolimus level on was 3.8. wound and blood culture serratia marescens was sensitive to ceftriaxone, cipro, ertapenem, gentamicin, imipenem, levofloxacin, tobramycin, and sxt. ekg on at osh showed junctional tachcardia at 146 bpm with lvh and old anterior infarct. . the patient was transferred to for further management and revision of his av fistula, as he was difficult to dialyze through the existing one. . on the floor, his initial vital signs were t 36.8(98.3), hr 78, bp 142/57, rr 18, sao2 96% 4l nc. he was somwehat sleepy and confused. he complained of pain in his left foot, but had no other complaints. past medical history: 1. wegener's granulomatosis - s/p renal graft - s/p left renal transplant - c/b nephrogenic systemic fibrosis 2. r bka secondary to trauma at age 52 3. copd (on steroids), emphysema 4. cad s/p cabg 7 years ago at 5. hypertension 6. l av fistula 7. monoclonal gammopathy igg lambda chains 8. skin cancers: - basal cell carcinoma: upper lip, right forehead - squamous cell carcinoma in situ: back social history: patient says that he lives alone. he has a girlfriend, , who (according to pt's daughter-in-law) "knows everything" about his medical history. the patient has 6 children; son is his hcp . daughter-in-law, , is a nurse in the cath on the at , and has permission to pass information along to hcp. - tobacco: previous - alcohol: none now, occasionally in the past - illicits: never family history: family history: - father died at 63 of heart failure. - mother died at 65 from surgical complciations - brother died at 47 from mi. physical exam: admission exam : t 36.8(98.3), hr 78, bp 142/57, rr 18, sao2 96% 4l nc general: awake, oriented to person, no acute distress, follows some commands heent: sclera anicteric, perrla, eomi, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: anteriorly, distant breath sounds throughout right lung. bibasilar crackles. cv: rrr, ii/vi systolic murmur @usb with radiation to lsb, no s1/s2 appreciated at usb. abdomen: soft, mild ttp in rlq, bowel sounds present, no rebound tenderness or guarding, no organomegaly; flexi-seal in place ext: lle erythema up ankle, slightly below where previously-marked border. extensive skin breakdown on foot: large yellow- eschar with surrounding erythema and draining sanguinous purulence starts on lateral dorsum extends to plantar surface and heel. digit 2 w/purulent lesion; digit 5 w/dark necrotic-appearing 1.5 cm round lesion. adaptik/kerlex dressings soaked with blood/pus. dp pulse dopplerable. rle well-healed bka, wwp. rue wwp, extensive antecubital ecchymoses/petechiae, good capillary refill. lue av fistula with palpable thrill and bruit on auscultation. extensive antecubital ecchymoses around bandage, good capillary refill. lines: right subclavian tlc discharge: gen: wdwn male in nad, alert and oriented x 3 cv: rrr, unchanged murmur lungs: cta bilat abd: soft, no m/t/o extremities: rle - well healed bka, warm and well perfused. lle - healing bka incision without erythema or drainage pertinent results: 05:41pm wbc-8.5 rbc-2.94* hgb-9.7* hct-28.6* mcv-97 mch-32.9* 05:41pm neuts-89.7* lymphs-7.0* monos-2.6 eos-0.6 basos-0.1 05:41pm pt-13.8* ptt-28.6 inr(pt)-1.2* 05:41pm glucose-111* urea n-48* creat-2.0* sodium-137 potassium-3.1* chloride-99 total co2-31 anion gap-10 . micro: blood cultures pending mrsa screen pending cdiff assay pending osh wound culture: serratia marescens (sensitive to ceftriaxone, cipro, ertapenem, gentamicin, imipenem, levofloxacin, tobramycin, and sxt) osh blood culture: serratia marascens . echocardiography report . , portable tte (complete) date/time: at 11:14 interpret md: , md echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.4 cm <= 4.0 cm left ventricle - septal wall thickness: *1.4 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.4 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.6 cm <= 5.6 cm left ventricle - systolic dimension: 2.9 cm left ventricle - fractional shortening: 0.37 >= 0.29 left ventricle - ejection fraction: 75% >= 55% left ventricle - stroke volume: 66 ml/beat left ventricle - cardiac output: 5.56 l/min left ventricle - cardiac index: 2.81 >= 2.0 l/min/m2 left ventricle - lateral peak e': 0.10 m/s > 0.08 m/s left ventricle - septal peak e': *0.06 m/s > 0.08 m/s left ventricle - ratio e/e': 11 < 15 aorta - sinus level: 3.5 cm <= 3.6 cm aorta - ascending: 2.6 cm <= 3.4 cm aortic valve - peak velocity: *3.8 m/sec <= 2.0 m/sec aortic valve - peak gradient: *57 mm hg < 20 mm hg aortic valve - mean gradient: 36 mm hg aortic valve - lvot pk vel: 1.46 m/sec aortic valve - lvot vti: 26 aortic valve - lvot diam: 1.8 cm aortic valve - valve area: *1.0 cm2 >= 3.0 cm2 mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 1.0 m/sec mitral valve - e/a ratio: 0.90 mitral valve - e wave deceleration time: 211 ms 140-250 ms findings left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. left ventricle: mild symmetric lvh. normal lv cavity size. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. normal ascending aorta diameter. focal calcifications in ascending aorta. aortic valve: ?# aortic valve leaflets. moderately thickened aortic valve leaflets. moderate as (area 1.0-1.2cm2) mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. moderate mitral annular calcification. mild thickening of mitral valve chordae. calcified tips of papillary muscles. no ms. trivial mr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. general comments: suboptimal image quality as the patient was difficult to position. suboptimal image quality - patient unable to cooperate. conclusions the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. there is moderate-to-severe aortic valve stenosis (valve area 1.0 cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is no pericardial effusion. . renal transplant us (l iliac fossa) - read pending . 7/26 l foot ap/lateral/oblique findings: three views of the left foot, with no prior for comparison demonstrate normal bony alignment, and osteopenia. there is no erosion, or periosteal reaction to suggest osteomyelitis. there is diffuse soft tissue swelling. there is no fracture. . cxr chest radiograph indication: copd, renal transplant, admitted for sepsis from cellulitis. now oxygen desaturation. comparison: . findings: as compared to the previous radiograph, there is no relevant change. unchanged monitoring and support devices, unchanged slightly elevated right hemidiaphragm with right basal atelectasis. unchanged moderate left retrocardiac atelectasis. no overt pulmonary edema. no newly appeared focal parenchymal opacity suggesting pneumonia. sternal wires in unchanged position. ct head w/o contrast study date of 11:30 am , vicu 11:30 am ct head w/o contrast clip # reason: r/o stroke medical condition: 73 year old man with new onset r blown pupil, hypertension. reason for this examination: r/o stroke contraindications for iv contrast: renal transplant provisional findings impression: 1:52 pm pfi: 1. no acute intracranial hemorrhage, mass effect, or area of hypodensity to suggest acute infarct. consider mri if not contraindicated for further evaluation if clinically indicated. 2. mild prominence of the ventricles, sulci and extra-axial csf spaces, likely due to atrophy. white matter hypodensity consistent with small vessel ischemic disease. 3. sphenoid septation inserts on the right carotid groove. final report indication: 73-year-old man with new onset anisocoria, right blown pupil, hypertension, rule out stroke. technique: contiguous axial images were obtained through the brain. no contrast was administered. findings: there is no evidence of hemorrhage, edema, mass effect, or obvious areas of hypodensity to suggest major acute infarction. there is mild prominence of the ventricles, sulci and extra-axial csf spaces consistent with volume loss. there are some periventricular white matter hypodensities likely due to chronic small vessel ischemic disease. the visualized portion of the paranasal sinuses and mastoid air cells are clear. the sphenoid septation inserts on the right carotid groove. the left ocular lens is not seen. bony structures are unremarkable. impression: 1. no acute intracranial hemorrhage, mass effect or area of hypodensity to suggest acute infarct. consider mri if not contraindicated for further evaluation if clinically indicated. 2. mild prominence of the ventricles, sulci and extra-axial csf spaces, likely due to volume loss. white matter hypodensities likely due to chronic small vessel ischemic disease. mra brain w/o contrast study date of 6:31 pm , vicu 6:31 pm mr head w/o contrast; mra brain w/o contrast clip # reason: non-contrast mri with tof; assess for intracranial pathology medical condition: 73 year old man with blown r pupil, ? compression of cn3 reason for this examination: non-contrast mra with tof; assess for intracranial pathology contraindications for iv contrast: transplant kidney with history of contrast-induced nephropathy to gadolinium final report indication: a 73-year-old man with blown right pupil. mri head and mra brain is requested. comparison: ct head of . technique: sagittal t1, axial t2, flair, diffusion-weighted, and gradient echo sequences of the brain were obtained. axial t1, axial t2 fat sat, and coronal t2 fat sat images of the skull base were obtained. 3d tof mra of the head was then performed. findings: mri head: there is prominence of bilateral lateral ventricles and sulci likely due to age-related atrophic changes. there is no acute intracranial hemorrhage, mass, mass effect, edema, or infarction. multiple t2 and flair hyperintensities are seen in bilateral periventricular white matter likely represent small vessel ischemic disease. no diffusion abnormalities are detected. the visualized orbits, paranasal sinuses, and mastoid air cells are unremarkable. mra brain: there is no flow signal identified within the left internal carotid artery. flow signal is detected within the major intracranial branch of the left ica, likely via collateral filling from the circle of . the right internal carotid artery, intracranial vertebral artery, basilar artery, and their major branches appear normal with no evidence of stenosis, occlusion, or aneurysm formation. a 1.4 x 2.3 cm soft tissue nodule is identified in the posterior aspect of the neck on the right side. impression: 1. complete occlusion of the intracranial left internal carotid artery, with preservation of flow within the left anterior and middle cerebral arteries, likely from collateral filling via the circle of . right internal carotid, bilateral vertebral, and basilar arteries and their major branches appear normal. 2. soft tissue nodule seen in the posterior aspect of the neck on the right side, may be further evaluated if clinically indicated renal transplant u.s. port study date of 2:41 pm , vicu 2:41 pm renal transplant u.s. port clip # reason: eval kidneys medical condition: 73 year old man with h/o renal tx, now with concern for rejection reason for this examination: eval kidneys final report indication: a 73-year-old man with history of renal transplant, now with concern for rejection. comparison: renal transplant ultrasound, . findings: the transplant kidney is again seen in the left lower quadrant measuring 12.5 cm in length. there is no hydronephrosis. there is linear shadowing echogenicity seen within the collecting system of the kidney likely representing air and related to foley catheterization. no perinephric fluid collection is identified. doppler examination: color doppler and pulse-wave doppler images were obtained. compared with the prior ultrasound of , there is now absent diastolic flow within the intrarenal and main renal arterial waveforms consistent with progressive high resistance flow within the transplanted kidney. resistive indices consequently measure 1.0. venous flow is identified within the main renal vein. impression: 1. no hydronephrosis seen in the transplant kidney. echogenicity within the collecting system likely represents air and is likely related to catheterization. 2. worsening high resistance flow pattern within the transplanted kidney, now with absent antegrade diastolic flow, which is a change from the prior ultrasound of . carotid lmtd/ dpp study date of 8:38 am , vicu 8:38 am carotid lmtd/ dpp clip # reason: cva- medical condition: 73m with total l ica occlusion on mra reason for this examination: evaluate for carotid disease bilaterally final report carotid series complete reason: known occlusion on mr. duplex evaluation was performed of both carotid arteries. patient was unable to stay still and there was instability by report. right side was only visualized. velocities are 117, 103, and 67 in the ica, cca, eca respectively. the ica to cca ratio is 1.1. this is consistent with 40% stenosis. incomplete study due to detailed above, 40% right carotid stenosis. left carotid was not well visualized. art dup ext up uni or lmtd port study date of 2:53 pm , csru 2:53 pm art dup ext up uni or lmtd por clip # reason: ? occlusion of lue av fistula medical condition: 73 year old man with lue swelling reason for this examination: ? occlusion of lue av fistula final report ultrasound fistulogram reason: swelling. duplex evaluation was performed of the left upper extremity surgical av fistula. brachial artery is patent with velocity of 181, anastomosis 442, drain vein 282, 120 and 493. impression: patent left upper extremity surgical av fistula. mild elevation of velocity at artery-to-vein anastomosis and at the distal portion of the draining vein. clinical correlation is warranted. carotid lmtd/ dpp port study date of 2:54 pm , csru 2:54 pm carotid lmtd/ dpp port clip # reason: left carotid only ( right side done yesterday) final report carotid series complete. duplex evaluation was performed of the left carotid artery. the right-side had been looked at another date. significant heterogeneous plaque is noted, velocities are 106, 72, 471 in the ica, cca, eca respectively. the ica to cca ratio is 4.2. this is consistent with less than 40% stenosis. however, diastolic velocities, especially in the common carotid artery are very limited, which may be consistent with more distal cervical carotid or intracranial carotid artery occlusive disease. impression: based on velocities, there is a less than 40% ica stenosis at the bifurcation. however, diminished diastolic velocities raise concern of more distal stenosis or occlusion. clinical correlation is warranted. egd : findings: esophagus: normal esophagus. stomach: contents: scant melena was seen in the fundus. duodenum: normal duodenum. other findings: two large (1.5-2 cm) necrotic ulcers were seen in the duodenal bulb. the more distal lesion was extending into the duodenal sweep which was difficult to traverse. within the sweep, there was a large and semi-circumferential mass concerning for a malignancy. the lesion was ulcerated and oozing fresh blood from various points. there was no single lesion approporate to intervene on and biopsies were not taken because of active bleeding. after completing the procedure with the therapeutic scope, dr. inserted the side-viewing scope for additional views. the ampulla was visualized and appeared unaffected. impression: blood in the fundus necrotic ulcers in the bulb and a large mass in the sweep concerning for malignancy. otherwise normal egd to third part of the duodenum 05:47am blood wbc-5.2 rbc-2.91* hgb-9.3* hct-26.8* mcv-92 mch-32.1* mchc-34.8 rdw-16.1* plt ct-148* 05:47am blood glucose-96 urean-30* creat-1.2 na-139 k-4.4 cl-104 hco3-28 angap-11 04:45am blood %hba1c-6.1* eag-128* 12:31 pm serology/blood source: line-picc. helicobacter pylori antibody test (pending): 9:01 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. 10:36 pm blood culture #2. **final report ** blood culture, routine (final ): no growth. 10:35 pm blood culture source: line-central line. **final report ** blood culture, routine (final ): no growth. 10:16 pm urine source: catheter. **final report ** urine culture (final ): no growth. 10:28 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). brief hospital course: 73m with pmh wegener's (s/p renal transplant on prograf) & traumatic r transferred from osh with resolving septic shock secondary to left lower extremity cellulitis and serratia bacteremia, here for further management and revision of his av fistula. . micu course () # septic shock: serratia bacteremia seeded from l lower extremity wound as cultured at osh. blood cultures sent again at time of this admission, and had no growth. septic shock resolved: off pressors for several days at osh, here he was normotensive without pressors and good urine output. creatinine was elevated but trended down to 1.2 at the time of discharge. patient has been treated with ceftazidime and levofloxacin since for serratia and other possible polymicrobial sources. started on vancomycin at time of icu admission, and continued hemodialysis begun at osh. his antibiotic was eventually changed to strictly levaquin which continued thru . . # left lower extremity cellulitis: extensive skin breakdown and impressive wet gangrene. on broad-spectrum antibiotics (as above) with non-resolving infection. podiatry and vascular surgery consult services evaluated his food. vascular surgery performed emergent l leg guillotine amputation and transfer to the cvicu. he then had a revision/closure of the bka. . # dialysis fistula: report of difficulty with dialysis via av fistula at osh. had been off dialysis for >2 years until this recent hospitalization, so there was concern clot formation in old fistula but renal transplant surgery evaluated and deemed it healthy with a good thrill, no stenosis, but anuresym possible. pt had an ultrasound which showed patency. . # wegener's ckd s/p kidney transplant: currently on prograf, imuran held during infection. given creatinine bump at osh (now trending down), underwent renal ultrasound to evaluate blood flow to graft, read pending. prograf levels were checked daily. he was followed by the nephrology transplant team throughout this stay . #cardiology issues patient complained of ongoing chest pain the morning after admission. serial cardiac enzymes were checked, with ck-mb negative and troponin elevated to 0.06. ekg within normal limits. also underwent a tte to evaluate degree of aortic stenosis; results appended. in brief, moderate-to-severe aortic valve stenosis (valve area 1.0 cm2) and mild (1+) aortic regurgitation. he did not have any further chest pain or cardiac events during his admission . # respiratory distress: was on nocturnal bipap at osh, now with o2 saturation >95% on supplemental oxygen. started albuterol and atrovent. noted skin breakdown on nose from osh bipap. weaned off without difficulty. . # nutrition: continuous tube feeds, eventually transitioned to liquid diet and then regular diet. at the time of discharge he is tolerating a regular diet. . # melena/anemia: pt was noted to have melanic stools after bka. gi was consulted and performed an egd. they found blood in the fundus, necrotic ulcers in the bulb and a large mass in the sweep concerning for malignancy with an otherwise normal egd to third part of the duodenum. he was placed on a ppi gtt and transfused as needed. a second egd was done showing the second part of the duodenum had ulcerations, erythema, some mild bleeding, friability and granularity in a patchy distribution. this may represent resolving severe duodenal ulcer disease, however there remains a concern for possible mass lesion. cold forceps biopsies were performed for histology at the second part of the duodenum. the biopsy ultimately came back negative for malignancy and showed active duodenitis with ulceration. he was continued on a ppi throughout his course and discharged on protonix 40mg . he will follow up for a repeat egd in a month. although there is no acute source of bleeding, he should have a hbg/hct checked twice per week. # prophylaxis: subcutaneous heparin # access: r subclavian line (placed at osh) was pulled when patient got picc line placed. # communication: patient, hcp son r-in-law (cath nurse) # code: full (discussed with hcp) # disposition: to rehab medications on admission: medications on osh transfer: 1. ceftazidime 1g q12 2. levaquin 500 mg q48 3. ativan prn agitation 4. silver sulfasalazine applied topically to affected leg 5. duonebs qid 6. albuterol as needed 7. protonix 40 mg iv daily 8. prednisone 5 mg daily 9. prograf home dose: 3 mg in morning, 2 mg at night 10. imuran (azathioprine), on hold 11. aspirin 81 mg daily, on hold 12. ssi 13. dilaudid 0.5 mg iv q4 prn pain 14. bipap discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation (2 times a day). 5. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 6. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for wheezing, sob. 7. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 8. tacrolimus 1 mg capsule sig: three (3) capsule po q12h (every 12 hours). 9. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* 10. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 11. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 12. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day): hold for hr<55 sbp<100. 13. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 15. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 16. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 17. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain or temp > 101.5. 18. sodium chloride 0.65 % aerosol, spray sig: sprays nasal daily (daily) as needed for dry nares. 19. temazepam 15 mg capsule sig: one (1) capsule po hs (at bedtime) as needed for insomnia. 20. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 21. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 22. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 23. insulin regular human 100 unit/ml solution sig: sliding scale injection asdir (as directed): check blood sugar before breakfast,lunch and dinner blood sugar dose 150-200 2u 201-250 4u 251-300 6u >300 md. 24. outpatient work please check hemaglobin/hematocrit twice weekly. discharge disposition: extended care facility: hospital - discharge diagnosis: 1. left lower extremity ischemia with wet gangrene of the foot 2. duodenitis with ulceration 3. anemia 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: discharge instructions following below knee amputation this information is designed as a guideline to assist you in a speedy recovery from your surgery. please follow these guidelines unless your physician has specifically instructed you otherwise. please call our office nurse if you have any questions. dial 911 if you have any medical emergency. activity: there are restrictions on activity. on the side of your amputation you are non weight bearing for 4-6 weeks. you should keep this amputation site elevated when ever possible. no driving until cleared by your surgeon. please call us immediately for any of the following problems: redness in or drainage from your leg wound(s). new pain, numbness or discoloration of your stump site. watch for signs and symptoms of infection. these are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. if you experience any of these or bleeding at the incision site, call the doctor. exercise: you should work with physical therapy daily and work on improving strength. limit strenuous activity for 6 weeks. do not drive a car unless cleared by your surgeon. try to keep leg elevated when able. bathing/showering: you may shower. no bathing. a dressing may cover you??????re amputation site and this should be left in place for three (3) days. remove it after this time and wash your incision(s) gently with soap and water. you will have sutures, which are usually removed in 4 weeks. this will be done by the surgeon on your follow-up appointment. wound care: when the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. these will stay on about a week and you may shower with them on. if these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. medications: unless told otherwise you should resume taking all of the medications you were taking before surgery. you will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (check with your physician if you have fluid restrictions.) if you feel that you are constipated, do not strain at the toilet. you may use over the counter metamucil or milk of magnesia. appetite suppression may occur; this will improve with time. eat small balanced meals throughout the day. cautions: no smoking! avoid pressure to your amputation site. no strenuous activity for 6 weeks after surgery. diet: there are no special restrictions on your diet postoperatively. poor appetite is expected for several weeks and small, frequent meals may be preferred. for people with vascular problems we would recommend a cholesterol lowering diet: follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and ldl (low density lipoprotein-the bad cholesterol). exercise will increase your hdl (high density lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. you may be self-referred or get a referral from your doctor. if you are overweight, you need to think about starting a weight management program. your health and its improvement depend on it. we know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. if interested you can may be self-referred or can get a referral from your doctor. if you have diabetes and would like additional guidance, you may request a referral from your doctor. follow-up appointment: be sure to keep your medical appointments. the key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. don't let them go untreated! please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. this should be scheduled on the calendar for seven to fourteen days after discharge. normal office hours are 8:30-5:30 monday through friday. please feel free to call the office with any other concerns or questions that might arise followup instructions: vascular surgery: provider: , md phone: date/time: 1:45 egd follow up (gastroenterology): you will need to be at this appointment at 12noon provider: room three phone: date/time: 1:00 provider: , md phone: date/time: 1:00 procedure: parenteral infusion of concentrated nutritional substances other endoscopy of small intestine enteral infusion of concentrated nutritional substances hemodialysis control of hemorrhage, not otherwise specified esophagogastroduodenoscopy [egd] with closed biopsy nonexcisional debridement of wound, infection or burn other amputation below knee repair of entropion or ectropion with wedge resection revision of amputation stump central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified anemia in chronic kidney disease coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis acute posthemorrhagic anemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified obstructive chronic bronchitis with (acute) exacerbation aortocoronary bypass status chronic kidney disease, unspecified occlusion and stenosis of carotid artery without mention of cerebral infarction ulcer of other part of foot personal history of other malignant neoplasm of skin cellulitis and abscess of leg, except foot pressure ulcer, other site diarrhea chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction duodenitis, without mention of hemorrhage surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation complications of transplanted kidney below knee amputation status gangrene cellulitis and abscess of foot, except toes ulcer of heel and midfoot acute osteomyelitis, ankle and foot pressure ulcer, stage ii septicemia due to serratia monoclonal paraproteinemia 

Answer: The patient is high likely exposed to