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 64-year-old man who was initially sent from the nursing home where he resides to on for gangrene of his right second and third toes. upon admission to his vital signs were temperature 97, heart rate 58, respiratory rate 16. he was alert and oriented times three and his physical exam was unremarkable other than the gangrene. laboratory data: initial labs were white blood cell count of 16.7 with 94% neutrophils, hematocrit 33.3, platelet count 240,000, sodium 136, potassium 4.1, chloride 103, co2 21, bun 63, creatinine 1.8, glucose 237 with anion gap equal to 12, albumin .7, normal lfts, ck of 153, ck mb 5.7. urinalysis was positive for nitrites with 11-20 white blood cells, 0-2 red blood cells and many bacteria with tract protein. initial chest x-ray showed left lower lobe pneumonia. the patient was then started on cipro. the final read of the chest x-ray showed chronic changes. however, blood cultures 4/4 bottles grew out mrsa. his antibiotics were changed from cipro to vancomycin and rifampin. repeat blood cultures from and have been negative to date. the patient's right foot was managed with local wound care. on the patient was found to become increasingly lethargic and bradycardic to a heart rate of 37. his left wrist was noted to be inflamed and his bun and creatinine increased to 85 and 3.6 respectively. his left wrist was tapped and grew gram positive cocci consistent with mrsa septic arthritis. atenolol was discontinued due to bradycardia. pacemaker was not placed due to mrsa bacteremia and because the patient was not hemodynamically stable. from to his bradycardia continued without improvement. a transthoracic echocardiogram was obtained for evaluation endocarditis and was notable for a large left ventricular thrombus, a decreased ef equal to 15-20% with globally decreased systolic function, moderate pulmonary hypertension, thickening of aortic valve, trace mitral, aortic, and tricuspid insufficiency. he was begun on heparin for the left ventricular thrombus. furthermore, the patient was noted to have colonic distention on kub consistent with an ileus. there were also reports of bright red blood per rectum. hospital course at was further complicated by oliguric acute on chronic renal failure. his renal function continued to deteriorate with a fena less than 1, consistent with a prerenal azotemia. on the patient was begun on dopamine for bradycardia, both sinus and junctional, with relative hypotension. the patient was then transferred to the micu for further management. past medical history: 1) coronary artery disease with history of a non q wave myocardial infarction on . 2) arteriosclerotic peripheral vascular disease, status post left bka, status post right 4th and 5th toe amputation. 3) type 2 diabetes mellitus requiring insulin with retinopathy, neuropathy and nephropathy. 4) gout. 5) depression. 6) question benign prostatic hypertrophy. allergies: penicillin. medications: outpatient medications: lipitor 20 mg , allopurinol 100 mg q d, nph 22 units q a.m., 16 units q h.s., humalog 2 units q a.m., 8 units at dinner, nitro patch 0.4 mg from 7 a.m. to 10 p.m., nitro 0.4 mg sublingual prn, celexa 40 mg q d, flomax 0.4 mg q d, q h.s., coumadin 2.5 mg q d, colace 100 mg q d, tylenol prn, milk of magnesia prn. medications on admission to : dopamine drip 7 mcg/kg/minute, wellbutrin 50 mg q d, lipitor 20 mg q h.s., colace 100 mg q d, nitro patch 0.4 mg on in the a.m. and off at night, flomax 0.4 mg q h.s., allopurinol 100 mg q d, celexa 40 mg q d, rifampin 300 mg , vancomycin renal dosing, insulin nph 11 units subcu q a.m., 8 units subcu q p.m. and a regular insulin sliding scale, heparin drip as per protocol. social history: the patient is a veteran. he denies any alcohol or tobacco use. he resides in a nursing home. the patient's son , is his health care proxy and is making all medical decisions for him. the patient's son is currently on duty for the national guard and available only by cell phone, . family history: significant for cardiac disease. hospital course: while in the micu, the patient's admission labs at were as follows: white blood count was 22.4 with 96% neutrophils, hematocrit 33, platelet count 353,000, sodium 125, potassium 4, chloride 92, co2 17, bun 109, creatinine 4.4, glucose 93, calcium 6.9, magnesium 3.2, phosphorus 7.5, albumin 2.8, alt 35, ast 47, ldh 291, alkaline phosphatase 117, total bilirubin 5.2, triglycerides 87, vancomycin level 13.5, lipase 85, troponin 1.9. ck 252. consults which were obtained during the patient's micu stay include id, renal, plastic, vascular and psychiatry. 1. id: the patient was initially begun on vancomycin and rifampin iv. later due to the patient's hyperbilirubinemia, rifampin was discontinued. plastics and hand surgery were consulted on suggesting an mri of the left hand and wrist when the patient was stable and to keep the wrist elevated at all times. wrist films on showed no evidence of osteomyelitis, however, were positive for osteopenia. urine cultures were positive for greater than 100,000 yeast. blood cultures have been negative to date. 2. vascular: vascular was consulted on and their recommendation was that the patient requires a right above the knee amputation since transmetatarsal amputation would not control the infection adequately. 3. cardiac: a pa catheter was placed on for management of acute renal failure. initial values were cvp 15, wedge 14, cardiac output was 3.4, later improved to 4.0, cardiac index 1.8, later improved to 2.1 and svf was normal. the patient was transfused two units of packed red blood cells and given fluid to keep wedge greater than 18, however, this did not improve renal perfusion. furthermore, dopamine drip was attempted to increase cardiac output and chronotropia, however, this caused his cardiac output to drop and svr to increase and therefore was discontinued. the pa catheter was pulled on and his blood pressure has since improved. transthoracic echocardiogram on showed a right and left atrium mildly dilated, mild symmetric left ventricular hypertrophy, left ventricular function is seriously depressed with a large left ventricular thrombus, severe global rv wall hypokinesis, tract ar, physiologic mr, 1+ tr, mild pulmonary hypertension, no echocardiographic evidence of endocarditis. the patient had a slight troponin leak without ekg changes or elevations in ck mb. currently aspirin was held given the risk of bleeding with pericarditis as well as patient being pre-op for surgery. the patient had episodes of rapid atrial fibrillation and svt, then returning to bradycardia in the 50's or 60's. his ectopy seemingly resolves with management of potassium and magnesium. a uremic friction rub was auscultated on indicating uremic pericarditis, hemodialysis was initiated for treatment of this. a heparin drip was continued for the left ventricular clot. at this point it was unclear if the clot was infected or not. 4. pulmonary: mild pulmonary edema by physical exam, however, patient was maintaining good oxygenation. 5. gi: the patient had a kub on which showed colonic ileus. reglan was started, however, later discontinued due to prolonged qt intervals. kub on showed resolving dilated bowel loops. the patient was found to have hyperbilirubinemia. his rifampin and lipitor were discontinued due to this. right upper quadrant ultrasound on showed sludge in the gallbladder, however, no pericholecystic fluid or gallbladder wall thickening or evidence of biliary obstruction. 6. renal: hemodialysis was initiated on for uremic pericarditis. the patient had a high phosphate level secondary to acute renal failure which was treated with calcium carbonate tid. urine was sent for urine sodium and creatinine and urine culture showing a prerenal picture. 7. heme: the patient was transfused two units of packed red blood cells on with good response of hematocrit from 28.2 to 35.1. the patient received a dose of epogen on . his iron level is 57, tibc is decreased at 146, trf is decreased at 112, ferritin is 356, consistent with anemia of chronic disease. 8. fluids, electrolytes & nutrition: ectopy is decreased with increasing the potassium during the dialysis. the patient's high phosphate level is treated with calcium carbonate tid and amphojel times two days. 9. psychiatry: it was recommended by psychiatry consult that wellbutrin and celexa be held at this point. his rpr was non reactive, his vitamin b12 was greater than , his folate was greater than 20 and his tsh was still pending in the micu. labs on when the patient was transferred to the medicine floor, white blood cells 21.3, hematocrit 33.2, platelet count 138,000, pt 15, ptt 67.8, inr 1.6, sodium 135, potassium 4.1, chloride 100, co2 24, bun 35, creatinine 2.1 and glucose 138, calcium 7.5, magnesium 2.1, phosphorus 3.2, total bilirubin 13.7. physical exam on admission to the medicine floor: vital signs were 97.4, blood pressure 112/74, heart rate 67, respiratory rate 15. in general, the patient was in no apparent distress, sluggish to response, sleeping yet arousable to voice. heent: scleral icterus, moist mucus membranes, slight thrush, right ij is in place. chest is clear to auscultation bilaterally from anterior, however, bibasilar rales. cardiovascular, regular rate and rhythm, normal s1 and s2, unable to appreciate friction rub. abdomen soft, nontender, minimal distention, positive bowel sounds. gu, scrotal edema. extremities, 2+ pitting edema bilateral lower extremities, 2+ pitting edema in bilateral upper extremities and hands. the patient is status post left bka. the patient's right foot is dressed in a multi podus boot. the patient's left wrist is dressed in a splint. impression: the patient is a 64-year-old man with a history of coronary artery disease and type 2 diabetes mellitus requiring insulin, admitted for mrsa bacteremia from primary infected gangrenous right foot. admission has been complicated by a septic left wrist, bradycardia, with tachycardic episodes, acute on chronic renal failure, uremic pericarditis and left ventricular thrombus. hospital course: while on . 1. infectious disease: the patient was continued on vancomycin, being dosed according to trough levels less than 15. vancomycin levels were checked q day to determine dosing. the patient was treated with nystatin swish and swallow to treat his thrush. the patient is currently awaiting mri for further evaluation of his septic left wrist. due to the 100,000 yeast noted in his urine, the patient's foley catheter was discontinued. 2. vascular: the patient was taken to the operating room on for a right guillotine bka. due to the patient's critical condition and after consultation with anesthesia, it was seemed safer to proceed with the guillotine right bka under mac anesthesia and to proceed with aka at a later date after some of the medical issues have resolved. the patient's right upper extremity was found to be cool on and right upper extremity ultrasound was performed which ruled out an upper extremity dvt. the patient will be taken back to the operating room within 5-7 days under general anesthesia to undergo a right aka. 3. cardiovascular: the patient continued to have episodes of supraventricular tachycardia and paroxysmal atrial fibrillation, alternating with relative bradycardia to the 50's and 60's. this is somewhat improved when the patient's potassium and magnesium are above 4 and 2 respectively. the patient is still medically too unstable to undergo pacemaker at this time, however, when his infection clears and after surgery is complete, ep studies will be done and the patient will require pacemaker. the patient was continued on heparin sliding scale for left ventricular thrombus treatment. it is not thought at this time that the thrombus is infected due to the fact that blood cultures obtained here at all have been negative to date. on the evening of the patient was believed to have had high blood pressure in the right arm ranging from the 200-300/dopplerable to blood pressures of 110-120/dopplerable in the left arm. the patient also was complaining of some vague upper back pain, therefore it was decided to rule the patient out for an aortic dissection. patient underwent ct with and without contrast of the chest with pretreatment of mucomyst and which showed no evidence of aortic dissection due to the absence of an intimal flap in the face of fluid density surrounding the anterior mediastinum adjacent to the ascending aorta. calcified aorta of normal caliber; a small pericardial effusion along with small left and trace right pleural effusion; left lower lobe patchy coapts adjacent to the effusion posteriorly; small amount of free fluid in the abdomen surrounding the liver, spleen and tracking to the right lower quadrant. chest x-ray at the time showed no enlargement of mediastinum and a left basilar opacity. it was determined with discussions with the attending that the patient's arteries are significantly calcified and therefore pose difficulty in obtaining appropriate blood pressures. when the patient was monitored that day in hemodialysis with a dinamap machine there were no problems getting his blood pressures and they ranged in the 100's to one teens over 50's to 60's. the patient has been continually monitored with the dinamap machine on the floor with no further issues with high blood pressure. 4. gi: most recently the patient's stools were guaiac negative. an abdominal ultrasound obtained on for evaluation of the biliary and urinary systems showed no signs of biliary or urinary obstruction and was positive only for gallbladder sludge. this study was obtained due to the patient's continued high creatinine as well as the patient's continued hyperbilirubinemia. 5. renal: the patient continues on hemodialysis approximately every other day. the patient was receiving hemodialysis through a left femoral quinton catheter until when the catheter was pulled. the patient will require placement of perma-cath on monday, in preparation for hemodialysis on tuesday, . 6. hematology: the patient is on heparin sliding scale for the left ventricular thrombus. his hematocrit was stable subsequent to his transfusions in the micu until when his hematocrit dropped to 28.7 and after surgery the patient's hematocrit was 27.8, therefore he was transfused one unit of packed red blood cells with good response to hematocrit of 30.3. the patient's pt, ptt and inr were monitored throughout his stay. it was noted by the blood bank that the patient had delayed transfusion reaction forming allo antibodies. this does not preclude him from getting further transfusions as the blood bank will merely screen for these antibodies in the future. 7. fluids, electrolytes & nutrition: when the patient was transferred out from the micu, he was on tube feeds running at 35 cc per hour. these were continued throughout his stay on the medicine floor. the patient began to take better po on being begun on a renal diet. calorie counts will be performed and need for tube feeding in the future via ng tube will be assessed. 8. endocrine: the patient is currently on a regular insulin sliding scale for his type 2 diabetes. he will be restarted on his nph regimen once adequate po intake is established. 9. psychiatry: the patient has a history of depression, we are holding his psychiatric medications as per psych consult's request. 10. code status: the patient is a full code. dr., 12-684 dictated by: medquist36 procedure: hemodialysis pulmonary artery wedge monitoring other amputation below knee diagnoses: acute kidney failure, unspecified atrial fibrillation methicillin susceptible staphylococcus aureus septicemia paroxysmal ventricular tachycardia paralytic ileus atherosclerosis of native arteries of the extremities with gangrene acute pericarditis in diseases classified elsewhere pyogenic arthritis, forearm 

Answer: The patient is high likely exposed to