Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: on pressor support central line placement picc line placement post-pyloric feeding tube placement transfusion of packed rbc history of present illness: 80 yo male with hx of schizophrenia, dementia was admitted to micu from ed after being found to be septic. patient was being transported to / for evaluation of vomiting x few days (2 or 4 days, depending on whose report you read). he was only responsive to verbal stimuli per ems notes. and per evaluation from the ambulance, his bp was 70/30, rr 30s and hr 60s. of note, patient has been having poor appetite x 4 days. kub was apparently negative for obstruction. . from his rn home, he was noted to have: - cr of 2.9 bun of 65 on and digoxin level of 1.5 - inr of 1.07 on and pt of 11.6 . in the ed: he was alert and following commands. initially bp responded to fluids and was in the 110s, then dropped to 67/59 - started on dopamine. he was also initially bradycardic to the 40s-50s (but then 110s for unclear reasons). dopamine was titrated to 10mcg/kg/min and then was placed on levophed at 0.5mcg/kg/min and then titrated up to 3mcg/kg/min. on arrival to the floor, he was on only levophed at 3mcg/kg/min. - increased pulmonary congestion and bipap was applied. - received 7l ns in ed - got levo/flagyl/vanco . access: a l groin was attempted. then a r ij was attempted - which led to guidewire getting stuck in the ivc filter. this was removed by vascular surgery. finally, a r femoral line was placed. past medical history: cad chf pvd dementia schizophrenia cri cardiac dysrhythmias social history: lives at long-term care facility. sister, , is his . family history: non-contributory physical exam: t:99.4 bp:109/62 p:112 rr:28 o2 sats:95% bipap gen: elderly man with nonsensical speech heent: cv: +s1+s2 quiet heart sounds. no murmurs appreciated. resp: mild crackles and decreased sounds at lung bases. abd: soft nt nd skin: warm. perfused. ext: rle with cellulitis from area below knee to above the ankle with area of increased erythema around r medial malleolus. - + dp and pt pulses b/l - need doppler to identify. neuro: patient moving extremities x 4 . ekg: tachycardia w/ rbbb pertinent results: labs on admission: 08:59pm blood wbc-17.0* rbc-3.77* hgb-11.8* hct-35.4* mcv-94 mch-31.3 mchc-33.3 rdw-15.9* plt ct-180 08:59pm blood neuts-76* bands-4 lymphs-6* monos-5 eos-6* baso-3* atyps-0 metas-0 myelos-0 08:59pm blood pt-16.8* ptt-27.4 inr(pt)-1.6* 02:05am blood fibrino-477* 02:05am blood d-dimer-2929* 08:59pm blood glucose-117* urean-81* creat-5.6* na-151* k-4.3 cl-108 hco3-25 angap-22* 08:59pm blood ck(cpk)-124 08:59pm blood ck-mb-3 08:59pm blood ctropnt-0.67* 08:59pm blood calcium-9.1 phos-4.0 mg-3.6* 03:47am blood cortsol-27.4* 11:25pm blood digoxin-1.3 11:40pm blood type- po2-140* pco2-45 ph-7.28* caltco2-22 base xs--5 09:00pm blood lactate-4.3* . pertinent labs during hospital course: 08:14am blood ck(cpk)-372* 04:00pm blood ck(cpk)-357* 06:00am blood ck(cpk)-242* 08:14am blood ck-mb-14* mb indx-3.8 ctropnt-1.22* 04:00pm blood ck-mb-11* mb indx-3.1 ctropnt-0.90* 06:00am blood ck-mb-6 ctropnt-0.57* 08:40am blood caltibc-156* vitb12-1080* folate-13.8 ferritn-543* trf-120* 01:15pm blood triglyc-125 hdl-28 chol/hd-3.9 ldlcalc-55 11:40pm blood glucose-113* lactate-2.9* na-149* k-4.0 cl-118* 08:24am blood lactate-1.3 . labs on discharge: 02:57am blood wbc-8.5 rbc-3.54* hgb-10.6* hct-32.3* mcv-91 mch-30.0 mchc-32.9 rdw-15.8* plt ct-203 02:57am blood neuts-71.6* lymphs-16.1* monos-3.7 eos-8.0* baso-0.6 02:57am blood pt-13.9* ptt-29.8 inr(pt)-1.2* 02:57am blood glucose-125* urean-14 creat-1.1 na-138 k-3.7 cl-109* hco3-19* angap-14 04:12am blood alt-13 ast-27 alkphos-82 totbili-0.4 02:57am blood calcium-8.3* phos-2.1* mg-1.7 . microbiology: blood cx: 2/2 bottles coag neg staph urine cx: mixed flora, contaminant blood cx: ngtd urine legionella: negative blood cx: ngtd sputum cx: oropharyngeal flora catheter tip cx: multimicrobial bacteria blood cx: ngtd urine cx: negative urine cx: negative . imaging: cxr: chest, single view: no prior for comparison. lung volumes are low. the cardiac shadow is slightly enlarged. aorta is ectatic. considerable right lung volume loss with collapse of right lower lobe and partial atelectasis right middle lobe with questionable cut-off of bronchus intermedius. although possibly due to secretions, an obstructing neoplastic mass should be considered. initial further evaluation with pa and lateral cxr is recommended. if persistent, contrast-enhanced ct would be recommended. . echocardiogram: conclusions: the left atrium is moderately dilated. normal left ventricular wall thicknesses and cavity size. there is moderate regional left ventricular systolic dysfunction with akinesis of the distal half of the inferior, septal, and anterior walls. the remaining segments are mildly hypokinetic. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is moderate to severe aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal left ventricular cavity size with extensive regional dysfunction c/w multivessel coronary disease. moderate to severe aortic valve stenosis. mild aortic regurgitation. pulmonary artery systolic hypertension. based on aha endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . bilateral lower extremity ultrasound: impression: 1. right deep venous thrombosis of indeterminate age (old clot per radiology) 2. no evidence of deep venous thrombosis involving the left lowerextremity. . cxr: conclusion: short-interval improvement in the aeration of the right lower lung field, with some residual opacities present in the right infrahilar region. . picc line placement. . nasogastric tube placement. brief hospital course: patient is an 80 year old male with history of cad, chf, dementia, schizophrenia, chronic renal insufficiency, cardiac dysrythmia who was admitted for sepsis. . 1. septic shock/infectious disease issues: patient presented from his nursing home with hypotension, leukocytosis, acute on chronic renal failure, indicating sepsis. initial studies demonstrated cxr with right lower lobe pneumonia, and u/a that was positive. patient also with some cellulitis in left lower extremity. therefore, intially thought source of sepsis was pneumonia vs uti vs cellulitis. cortisol stimulation test was negative, ruling out adrenal insufficiency on admission. the patient was fluid rescusitated and initially started on levaphed for pressor support. he was maintained on vancomycin and zosyn for broad spectrum antibiotics coverage. shortly after admission, patient had improved blood pressure and levaphed pressor was weaned off. blood cultures from admission grew coag negative staph, 2/2 bottles, likely source of this infection being his left lower extremity cellulitis. therefore he was maintained on vancomycin to complete a 14 day course. wound care nursing was also consulted and dressing changes were applied per their recommendations. for his pneumonia, sputum culture did not grow any bacteria. urine legionella antigen was negative. therefore patient was empirically treated with vancomycin to complete a 14 day course, as above, and zosyn, which was converted to levofloxacin on discharge, for gram negative coverage to complete a 7 day course. for his presumed uti, the patient had 2 positive u/a's during the hospital course, with negative urine cultures. the 3rd u/a prior to discharge was negative, with a corresponding negative culture. therefore, upon discharge, patient had a very stable blood pressure, stable oxygenation off of oxygen, and was discharged on vancomycin to complete a 14 day course and levofloxacin to complete a 7 day course (started with zosyn). he had a picc line placed prior to discharge. . 2. cardiac: a. ischemia: patient has a history of coronary artery disease. on presentation, ekg demonstrated right bundle branch block (last ekg in our system is from that demonstrates no rbbb - however, obtained outside hospital records that does show rbbb, so not new). on admission, cardiac enzymes were elevated. cardiology was therefore consulted. patient was thought to be having a demand ischemic event, and therefore was started on heparin drip to complete 48 hours per cardiology recommendations. his outpatient aspirin dose was increased from 81mg to 325mg daily. he initially could not be on beta blocker therapy given his hypotensive sepsis. upon resolution of his hypotension, his outpatient lopressor was re-started and titrated up to his outpatient dose of 50mg . his ck peaked at 372, and cardiac enzymes trended down throughout remainder of hospital course. no plans for cardiac catheterization given the nature of his mi in setting of sepsis, and his co-morbid conditions. b. rhythm: patient had a known history of some cardiac dysrhythmia, but unknown type. during hospital course, patient was noted to have strange rhythm on telemetry and ekg. the electrophysiologist cardiologists were curbsided, and believed the patient's rhythm to be due to wenkebach rhythm. they recommended no further intervention and believed that the patient's outpatient digoxin could be discontinued. otherwise patient was maintained on lipitor, as above. c. pump: patient has a history of chf, and was on lisinopril and lasix and digoxin as and outpatient. all of these medications were held on admission due to the patient's renal failure and sepsis. echo on admission demonstrated diffuse disease, ef 20-25%, mod-severe aortic stenosis, mild aortic regurgitation, mild-mod mitral regurgiation. upon resolution of the patient's sepsis/hypotension, his lisinopril was restarted. digoxin and lasix were not restarted. spironolactone was initiated given the patient's heart failure and low ef. he remained euvolemic during remainder of hospital course. . 3. acute on chronic renal failure: patient with a history of chronic renal insufficiency with baseline creatnine thought to be 2.0. on day of admission, cr was elevated at 2.9 and quickly rose to peak of 5.6. patient was fluid rescusitated and cr dropped throughout admission and was down to 1.1 at time of discharge. during hospital course, the patient's lisinopril, lasix, and digoxin were held due to the patient's renal failure. only his lisinopril was restarted, as above. his antibiotics were renally dosed and adjusted throughout hospital course. . 4. anemia: patient had a hematocrit of low 30's on admission, trended down to low of 26 during hospital course. iron studies were consistent with anemia of chronic disease. patient was transfused 1 unit of prbc for hct of 26, given his history of cad, and hct bumped appropriately to 29, and remained stable during remainder of . ? baseline. hct increased to 29 w/ 1 unit prbc. plan to: - will f/u iron studies - guaiac all stools - tfs to keep hct > 28 - moniter . 5. facial eccymoses and erythema: patient had noted left sided peri-orbital facial erythema and eccymoses on exam on . radiology and opthalmology were contact as this was thought possibley secondary to peri-orbital cellulitis. mri scan was initially considered for futher evaluation. however, opthalmology evaluated the patient and thought it was unlikely to be peri-orbital cellulitis, and therefore no imaging was necessary. this exam finding was thought likely secondary to the heparin drip that the patient was on for his cardiac issues, and continued to improve throughout remainder of hospital course once heparin was discontinued. . 6. guidewire caught on ivc filter: patient had a right ij guidewire get caught in his ivc filter during his ed course. this was removed by vascular surgery. patient was given 1u prbc in ed for fear of bleed. hematocrit remained stable. nothing further was done. . 7. mental status: patient was somnolent on admission, likely secondary to his infectious status. he returned quickly to his baseline mental status that included being awake, alert, pleasant, responsive, oriented only x 1 to person. he was written for zyprexa 5mg prn for agitation, but did not receive any during hospital course. . 8. peripheral vascular disease: patient had dopplerable pulses on this admission. . 9. coagulopathy: patient on coumadin as outpatient for dysrhythmias and lower extremity dvt. coumadin was initially held given the patient's poor clinical condition. it was restarted during hospital course, and he was discharged on his outpatient dose of 1mg qhs, with a subtherapeutic inr. it should be addressed with his outpatient primary care physician whether or not to continue his coumadin, given his fall risk and his risk vs benefit ratio. . 10. hypernatremia: patient was quite hypernatremic during hospital course, with sodium of 151 on admission. this was thought likely a hypovolemic hypernatremia. his hypernatremia improved slightly with initial fluid rescusitation. the patient then proceded to get free water boluses per his ng tube, which continued to control his hypernatremia. . 11. nutrition: patient underwent speech and swallow evaluation early in hospital course which he failed. therefore he had an ng tube placed and received tube feeds and medications per his ng tube. upon improved alertness, patient underwent a repeat bedside speech and swallow evaluation, which he also failed. following this, patient lost his ng tube. he therefore had an ir placed post-pyloric feeding tube to continue his tube feeds and medications. he was discharged with this tube in place with plans for a repeat speech and swallow upon improvement at rehab. if he fails this, the issue of peg tube placement should be brought up with his , his sister . . 12. prophylaxis: patient was initially maintained on heparin drip for his non st elevation mi for dvt prophylaxis, which was changed to subcutaneous heparin after 48 hours. he was also re-started on his coumadin as above. he was also maintained on a ppi. . 13. access: picc line was placed prior to discharge. . 14. code: dnr/dni - per nursing home records and confirmed by , his sister. . 15. contacts: (sister and ) (, nursing home (, pcp . (. medications on admission: meds: - coumadin : 1mg po qd - lopressor: 50mg po bid - zyprexa: 5mg qhs - vicodin: 5/500: 1 tab po qd 1 hour prior to dressing change - lanoxin-digoxin : 1 tab po qd - omeprazole: 1 tab po bid - mvi - lasix : 40mg qd - lisinopril: 5mg po qd - asa : 81mg qd - vitamin c - mom: prn - dulcolax: prn - fleet enema : prn - maalox: prn - tylenol: prn -robitussin : prn - duonebs prn - cepacol lozenges discharge medications: 1. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)) as needed. 2. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. erythromycin 5 mg/g ointment sig: one (1) aplication ophthalmic qid (4 times a day) for 4 days. 7. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 8. warfarin 1 mg tablet sig: one (1) tablet po daily (daily): please adjust dose to achieve inr of 2. 9. metoprolol tartrate 25 mg tablet sig: two (2) tablet po bid (2 times a day): please hold for sbp < 100, hr < 60. 10. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily): please hold for sbp < 100. 11. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 12. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 13. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 14. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily): per nasogastric tube. 15. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 16. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. 17. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q 24h (every 24 hours) for 9 days. 18. picc line care picc line care per protocol 19. picc line care please flush picc line per protocol discharge disposition: extended care facility: - discharge diagnosis: sepsis urinary tract infection pneumonia coag negative staph bacteremia wenkebach cardiac dysrrhythmia non st elevation myocardial infarction acute renal failure discharge condition: stable. discharge instructions: please contact physician if develop worsening cough, chest pain/pressure, shortness of breath, fever, low blood pressure, any other questions/concerns. . please take medications as directed. . please follow up with physician as directed. followup instructions: please follow up with primary care physician, . in the next 1-2 weeks. can contact him at (. procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances transfusion of packed cells infusion of vasopressor agent diagnoses: pneumonia, organism unspecified anemia in chronic kidney disease subendocardial infarction, initial episode of care urinary tract infection, site not specified acute kidney failure, unspecified severe sepsis other persistent mental disorders due to conditions classified elsewhere chronic kidney disease, unspecified unspecified schizophrenia, unspecified rheumatic heart failure (congestive) cellulitis and abscess of leg, except foot septic shock long-term (current) use of anticoagulants multiple involvement of mitral and aortic valves anticoagulants causing adverse effects in therapeutic use hyperosmolality and/or hypernatremia atherosclerosis of native arteries of the extremities with ulceration other staphylococcal septicemia ulcer of ankle spontaneous ecchymoses 

Answer: The patient is high likely exposed to