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: history of present illness: the patient is a 63 year old spanish speaking male with a long and complicated medical history, significant for diabetes mellitus, end-stage renal disease on hemodialysis, hypertension, coronary artery disease, and history of multiple lung infections, now presenting with a left line site pain. review of systems is positive for nausea and vomiting, pain is also significant along the spine in the back and along the legs, positive history for malaise, increased shortness of breath, and a non-productive cough. the patient denies any abdominal pain, dysuria, or diarrhea. his previous medical history is very involved. the patient was last admitted in for a superior vena cava syndrome, occluded superior vena cava secondary to stenosis, and possible deep vein thrombosis. the left internal jugular was removed at that time. the patient was treated with coumadin and received hemodialysis through a femoral line at that time. in , the arteriovenous fistula was unrepairable and was removed in . a magnetic resonance arteriography showed an occluded right system. the patient was receiving dialysis through a left subclavian line which now appears to be infected. review of systems: positive for chills. past medical history: 1. end-stage renal disease, the patient receives hemodialysis on monday, wednesday, and friday at where he is also followed by his primary care physician. 2. history of multiple line infections. methicillin resistant staphylococcus aureus, vancomycin-resistant enterococcus, and klebsiella recently in , vancomycin-resistant enterococcus in . 3. diabetes mellitus. 4. coronary artery disease, status post percutaneous transluminal coronary angioplasty stent in left circ, status post myocardial infarction. 5. osteo-spine with previous line infection. 6. chronic obstructive pulmonary disease. 7. congestive heart failure. 8. right internal jugular thrombosis and right subclavian thrombosis as well as thrombosis of the superior vena cava leading to a superior vena cava stenosis-like syndrome. 9. peripheral vascular disease. 10. hypertension. 11. arteriovenous fistula thrombosis. 12. atrial fibrillation paroxysmal, an echo in showed a normal ejection fraction. home medications: 1. amlodipine 10. 2. aspirin. 3. protonix. 4. coumadin. 5. nephrocaps. 6. lactulose. 7. morphine. 8. atenolol. 9. norvasc. 10. zyprexa. allergies: no known drug allergies. social history: does not use alcohol or smoke cigarettes. has been living with one woman for the majority of his life. they are not married. at this time, she is his caretaker. physical examination on admission: temperature 101.2; heart rate 75; blood pressure 150/68; respiratory rate 18; oxygen saturation rate 95% on room air. general: patient is lying in bed, breathing comfortably. head, eyes, ears, nose and throat: pupils are equal, round, and reactive to light and accommodation, anicteric sclera. neck: supple, no lymphadenopathy. chest: decreased breath sounds to the bases with rails on deep inspiration. cardiovascular: large systolic murmur, no rubs, gallops, murmurs, consistent with previously documented murmur. abdomen: soft, non-tender, non-distended, bowel sounds are present. extremities: trace edema, warm, weak pulses in lower extremities bilaterally, dorsalis pedis pulses. neurological: alert and oriented times three, no focal deficits to gross confrontation. labs: white count normal 15.1; blood cultures pending. hospital course: the patient had a very long and complicated hospital course. 1. infectious disease. the patient had a line infection and was initially placed on vancomycin and gentamycin. the gentamycin was continued for five days. his doses were checked with the levels in hemodialysis and dosed accordingly. the patient's blood cultures grew out a skin sensitizing antibody. the patient was changed to oxacillin which was started on . due to the back pain and the patient's history of osteo to the spine with prior line infections, there was concern over a receding of these bones. it was decided that the patient would need a long course of intravenous antibiotic therapy secondary to possible osteo as well as ceding of multiple known blood clots. due to his heart murmur, there was also a question of endocarditis which was evaluated. on the 20th, the patient's blood sedimentation rate was 449, his white count 16.8. the patient's back pain was evaluated with a magnetic resonance scan of the cervical spine initially which showed an early inflammatory process, though this was greatly resolved from the last study. this was thought to be resolving from his prior episode of osteomyelitis and not representing a new condition. the patient also had a magnetic resonance scan of the lumbar spine much later in his hospital course that showed no osteo, no discitis which was relevant for possible abscesses or hematomas in the psoas muscle which will be discussed in a later section. the patient had a transthoracic echocardiography initially to evaluate valvular changes. the transthoracic echocardiography showed the left atrium mildly dilated, a left to right shunt across the internal atrial septum, consistent with a secundum-type atrial septal defect, mild symmetric left ventricular hypertrophy, and ejection fraction greater than 55. there was, compared to the prior study, new aortic regurgitation and the severity of mitral regurgitation was slightly increased as this was suspicious for endocarditis. a transesophageal echocardiography was ordered. the patient initially refused the first attempt on . the patient did undergo a transesophageal echocardiography on . no spontaneous echocontrast or thrombus was seen. no vegetations were noted. the left ventricular ejection fraction was consistent with greater than 55%. there were abnormally thickened aortic valve leaflets with a non-mobile focal echogenic structure, probable calcifications of the non-coronary cusp, trace aortic insufficiency, and no aortic abscess. 2. abnormally thickened mitral valve encarditis with trace mitral regurgitation. moderate mitral annular calcification, no vegetations. abnormally thickened tricuspid valve, no vegetations were seen. the possibility of endocarditis could not be excluded. the patient was treated with intravenous oxacillin beginning on which was changed to intravenous cephazolin on as this is dosed during dialysis and did not require peripheral intravenous access and could be dosed as an outpatient during dialysis sessions. the patient continued to spike from to . the patient then remained afebrile and stable throughout the rest of his hospital admission. 3. access. the patient had his initial infected line changed over a wire on as his inr was 2.1 and interventional radiology felt uncomfortable removing the line with this level of coagulation. anticoagulation was held. the patient was given vitamin k as well as fresh frozen plasma. the line was removed and his hematocrit stabilized. a pic was added on for intravenous antibiotics as the patient had pulled out most of his remaining peripheral access. on day 14 of intravenous antibiotics, a permanent central dialysis catheter was placed and his stem dialysis line which had been placed on was removed on . a vascular mapping study was done on the 13th and transplant will follow-up with these results to evaluate for further fistula work-up. the patient accidentally broke off one line of his pic on and then this line was self discontinued on . the patient went home with stable and working dialysis access. 4. hematology. the patient initially presented on coumadin for his paroxysmal atrial fibrillation. this was changed to heparin to allow adjustments in his lines. in interventional radiology, the patient had his line changed over a wire on . he was noted to have a large bleed at that time. this will be discussed under the cardiovascular section. on the patient complained of some pain in his left thigh. there was palpable pain over the lower abdomen and thigh area. the patient had been on heparin sliding scale and had one dose that was over 150 ptt. this was adjusted accordingly. this pain began after this high supertherapeutic level. an ultrasound was performed on the left thigh which showed no fluid collection, no abscess. on the day of , the patient's hematocrit was noted to drop from 31.5 to 25.6. he developed an anion gap of 18. his ck increased to 263 while his ckmb remained normal. the patient was afebrile. there was no obvious source of bleed. the patient had one unit of blood transfused. he had dic labs performed which were negative. the patient was taken for a ct of the pelvis with no doubt a huge retroperitoneal bleed on the left which was 8 x 10 cm. the heparin was discontinued at that time and vascular surgery was consulted. the patient was transferred to the intensive care unit from to where he received 8 units of packed red blood cells and 1 unit of fresh frozen plasma. all anticoagulation was held. the patient received dialysis while in the intensive care unit, but clotted his femoral dialysis access. this was changed over a wire while the patient was in the intensive care unit. his hematocrit remained stable and he was transferred back to the floor on the 10th. the patient's prior records of hematology consults were reviewed in regards to his superior vena cava syndrome on which was noted for a questionable decrease in protein s. his superior vena cava was secondary to stenosis and thrombosis. at that time, he was started on three months of anticoagulation. the patient was evaluated by hematology for further coagulation difficulties. the patient developed anemia and was started on epogen and hemodialysis. the patient was transfused to keep the hematocrit above 30 throughout admission. on , the patient's ptt was noted to once again be 150. this was unusual as he was not on anticoagulation except heparin during his hemodialysis sessions. renal, vascular, and transplant team discussed the issue of long-term coagulation with the medical team. it was felt that, in light of the patient's need for adequate dialysis access and his history of clotting his lines and fistulas, that his risk of re-bleed was well worth his risk for clotting off all access that was necessary to provide life saving and sustaining dialysis. the patient was started on a light heparin sliding scale with the goal ptt of 50 to 80 and then change to coumadin. his ptt was difficult to control and once again at one point was 132. his inr increased to 4.6 and all coumadin and heparin were held. the patient's inr continued to increase off coumadin and off sliding scale heparin. the patient was only receiving heparin in dialysis. the patient had a large hematology workup at that time to evaluate his difficult to control coagulations. it was thought that his elevated inr was secondary to an elevated ptt which was the result of heparin dosed only during dialysis. all anticoagulation was held. the patient was monitored until his inr was within a therapeutic range. at 1.4, the patient was started back on his home dose of coumadin at that time and discharged home for close follow-up for monitoring of his inr and coagulation levels during dialysis. 5. renal. the patient has end-stage renal disease on hemodialysis. the patient received dialysis throughout his hospital course. his volume status was adjusted multiple times in dialysis. he was evaluated for peritoneal dialysis as he has a history of infections and problems thrombosing his dialysis lines. it was felt that he was not a candidate for peritoneal dialysis at this time. the patient developed increased itch, secondary to uremia, and increased phos absorption after his large retroperitoneal bleed, secondary to reabsorption of this bleed. he was started on three days of amphojel and improved with the help of the hemodialysis team. the patient was also started on as benadryl caused a change in mental status. this was followed by hemodialysis and electrolytes were adjusted accordingly. 6. cardiovascular. the patient had a history of paroxysmal atrial fibrillation and was in and out of atrial fibrillation throughout his hospital course. the patient had the infected line changed over a wire on . that evening, a large amount of blood was noted on his bedsheets, presumably from the site of line change. his hematocrit dropped from 31 to 25 over the course of . he complained of crushing chest pain and his troponin was 0.1, mb was 2, and ck 126. his electrocardiogram showed st depressions in v4 through v5. the patient complained of his sharp back pain. there was a question for aortic dissection. his pain resolved with nitroglycerin and 2 units of blood, as well as nitroglycerin paste. it was felt that this was likely demand ischemia. the patient was taken to ct which showed no dissection, but bilateral pulmonary effusions as well as a consolidation consistent with infection versus septic emboli. the patient was evaluated with a transthoracic echocardiography which has been described previously. in the ct, the patient desatted to an 02 sat in the 50s but was quickly revived and satted at 100% on 2 liters of oxygen. the patient's electrocardiogram slowly resolved over time. the patient did not complain of any further chest pain until the morning of . the patient was refused at dialysis because of this chest pain. he responded to nitroglycerin. similar electrocardiogram changes were noted with st depressions in v5. the patient was found on to be 3 kilos down at hemodialysis. it was thought this second episode of chest pain was also likely to be secondary to demand ischemia. the patient improved with fluids. the patient had frequent electrocardiogram checks and these changes fully resolved over time. the patient was on adequate cardiac therapy with beta-blockers, ace inhibitors, aspirin, and anticoagulation. he did develop some hypotension on lopressor, but responded to a bolus during this period of volume depletion. volume depletion was likely secondary to 3 days of nausea and vomiting. 7. gastrointestinal. the patient experienced a 3 to 4 day period of nausea and vomiting that preceded his 3 kilo volume loss prior to the incidents described on . this nausea and vomiting was self limited. the patient responded to boluses as well as increased by mouth intake. 8. pulmonary. initial ct showed questionable consolidation at the right lung base. a repeat ct showed a 13 mm nodule at the right lung base which was assessed by pulmonary consult. they felt this was likely a resulting septic emboli and recommended a follow-up ct as an outpatient. a percussion and postural drainage was also placed which was read as negative. 9. mental status changes. the patient had noticeable mental status changes starting and persisting through the beginning of . over the weekend of , the patient required zyprexa, risperdal, and restraints. apparently, the patient had tried to bite a staff member and pulled out most of his peripheral lines. it was thought the patient was sundowning as well as having a negative response to benadryl. as patient's temperature resolved, the medical condition stabilized and his mental status changes resolved. discharge diagnosis: 1. methicillin-susceptible staphylococcus aureus line infection with possible septic emboli to the lung. 2. possible endocarditis. 3. status post large retroperitoneal bleed 4. end-stage renal disease on hemodialysis. 5. diabetes mellitus type ii. 6. coronary artery disease with demand ischemia. 7. allergy. 8. possible coagulopathy. 9. possible acquired factor 8 deficiency. recommended follow-up: 1. the patient will proceed to dialysis three times a week. 2. the patient will have his inr, pt, and ptt checked monday at dialysis or by his home nursing. 3. he will contact dr. with his coagulations. 4. dr. will contact patient to adjust his warfarin dose. 5. the patient will follow-up with in the transplant center. 6. the patient will follow-up with dr. for adjustment of his warfarin. 7. the patient will follow-up with dr. in the next few weeks, his primary care physician. discharge condition: fair, tolerating by mouth, minimal walking, no nausea, vomiting, or diarrhea. his inr is down to 1.2 on the day of discharge. discharge medications: 1. docusate sodium. 2. senna. 3. folic acid, vitamin b. 4. pantoprazole 40. 5. nitroglycerin sublingual as needed. 6. metoprolol 100 three times a day. 7. insulin regular sliding scale. the patient reports he uses a regular sliding scale at home and is familiar with its use. 8. enalapril 10. 9. amlodipine 10 once daily. 10. fexofenadine 60 once daily as needed for itch. 11. sarna lotion. 12. aspirin 325 once daily. 13. warfarin 7.5 once daily or as instructed by physician. 14. epogen alpha with hemodialysis. 15. cephazolin at hemodialysis. , m.d. dictated by: medquist36 procedure: diagnostic ultrasound of heart hemodialysis venous catheterization for renal dialysis diagnoses: congestive heart failure, unspecified acute posthemorrhagic anemia chronic airway obstruction, not elsewhere classified atrial fibrillation methicillin susceptible staphylococcus aureus septicemia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease infection and inflammatory reaction due to other vascular device, implant, and graft hemorrhage, unspecified congenital deficiency of other clotting factors 

Answer: The patient is high likely exposed to