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: atenolol attending: chief complaint: altered mental status and fever major surgical or invasive procedure: none history of present illness: 62 male with pmh cabg, dm2, htn, ckd, sciatica, and depression who presents with acute mental status change. the patient was unable to give a clear history due to mental status. called his case manager at inn. she was unsure of the exact history, but states that he has been "sick" for the last 2 months. she states that he was complaining of abdominal pain, fatigue, and malaise. he had complaints of vomiting all night 6 days pta and wasn't able to sleep. she said that he was going to get a "mri of his abdomen" at the va for workup of his vomiting. she did not notice any wounds or lesions on his skin previosuly. the next time she spoke with the patient was 3 days pta and she said he was in good spirits. she saw him this morning and he was extremely confused and not coherent. she states he is normally a very intelligent and responsible person. she was extremely worried and called the ambulance and had him transferred to the ed. . in the ed: 98.7 165/93 99 18 100% ra his initial fs was 393. blood cultures were sent. the patient was found to have a large erythematous hard collection on his left shoulder and multiple small pustules. a u/s of the back did not show fluid collection. he was started empirically on vancomycin 1gm and unasyn 3g iv. his k was 5.9 and patient was given ca gluconate, 10u insulin & amp of d50 and kayexalte. a urine tox was sent and the patient was transferred to the floor. . on the floor: vs 100.5 158/114 114 18 98%ra the patient was found to be extremely lethargic and minimally responsive. he was able to answer yes/no questions. he was given 10u insulin. intial vbg: 7.36/27/40/16, abg: 7.51/18/101/15. cxr was performed. the patient was ordered for abdominal/pelvis ct and head ct. foley was placed and patient drained 1.7l. . ros: unable to obtain. past medical history: diarrhea since htn dm type 2 hypercholesterolemia s/p cabg x 5 depression (suicide attempt ) s/p penile implant (mri compatible) gerd vertigo sciatica social history: no tobacco. etoh described as occasional wine, used to drink more but not currently, denies h/o alcohol abuse. history of cocaine and marijuana use, last in , denies ivdu. sexually active with same male partner for past 5 years. family history: no family history of premature coronary artery disease or sudden death. father has history of dm, died at age 89. mother has history of skin ca. physical exam: on admission: vitals: t:100.5, bp:158/114, hr:114, rr:18, 02 sat:98% gen: lethargic and minimally responsive heent: at/nc, dilated pupils that are sluggish, anicteric, no conjuctival pallor, dry mm, neck: supple, trachea midline, no lad lung: cta-b/l cv: s1&s2, rrr, no r/g/m abd: obese/soft/+bs/ distended/ +fluid wave/ +grimace to palpation in his abdomen/ no rebound/ no guarding ext: no c/c/e skin: multiple scabbed lesion on his arms and back/ erythematous, draining, hard collection on le shoulder, drianing tract and macerated. neuro: minimally awake and not oriented. unable to test cranial nerves, dilated pupils that are minimally reactive to light. could not test strenght or sensation reflexes brachioradialis, biceps, triceps, patellar, achilles . on floor: vitals: hr 100, bp 140/90, rr 16, o2 97% ra gen: aao x 3, slow speech with some alternate word choices but denies any word finding difficulties, abnormal thought processing. heent: perrl, eomi cvs: reg rhythm, tachycardic, s1-s2+, no m/r/g lungs: cta b/l abd: bs+, soft, nt/nd ext: no le edema b/l neuro: aao x 3 with abnormal affect. skin: l shoulder large area of erythema/excoriation/pustular lesion satellites, edematous and able to express purulent discharge. across left arm are scattered lesions, dime-sized with central ulcerations, surrounding heaped borders of pearly erythema, pruritic per pt. pertinent results: on admission 10:20am blood wbc-15.4*# rbc-4.65# hgb-13.0*# hct-37.6*# mcv-81* mch-27.9 mchc-34.5 rdw-14.5 plt ct-438 10:20am blood neuts-90.5* lymphs-5.7* monos-2.5 eos-1.2 baso-0.2 04:37pm blood pt-15.7* ptt-33.5 inr(pt)-1.4* 10:20am blood glucose-337* urean-82* creat-4.0*# na-133 k-5.9* cl-104 hco3-16* angap-19 10:20am blood alt-16 ast-19 ld(ldh)-250 alkphos-134* amylase-64 totbili-0.1 05:40pm blood calcium-8.8 phos-3.8 mg-2.1 06:01pm blood freeca-1.22 10:20am blood albumin-2.6* 09:06pm blood cortsol-28.9* . on transfer to floor 04:00am blood glucose-145* urean-45* creat-2.3* na-143 k-3.8 cl-117* hco3-14* angap-16 . on discharge 06:30am blood wbc-6.4 rbc-3.83* hgb-10.3* hct-29.7* mcv-78* mch-26.9* mchc-34.7 rdw-15.1 plt ct-328 06:30am blood glucose-66* urean-24* creat-1.7* na-139 k-4.2 cl-114* hco3-19* angap-10 06:30am blood calcium-7.8* phos-3.7 mg-2.0 07:07am blood alt-35 ast-32 alkphos-102 totbili-0.6 . lipase trend 10:20am blood lipase-202* 05:16am blood lipase-251* 12:48pm blood lipase-90* 04:00am blood lipase-34 . anemia studies 07:30am blood vitb12-1093* folate-6.2 05:16am blood iron 10 caltibc-160* ferritn-403* trf-123* . drug screens 10:20am blood asa-neg ethanol-neg acetmnp-5.9 bnzodzp-neg barbitr-neg tricycl-pos 04:00am blood tricycl-pos amitriptyline 134 06:45am blood tricycl-neg . 09:06pm blood cortsol-28.9* 07:30am blood tsh-1.2 06:43am blood lactate-1.0 07:15am blood hiv ab-negative 05:00am blood psa-7.5* . ekg: sinus tachycardia. inferior myocardial infarction, age undetermined. poor r wave progression. consider anterior myocardial infarction. non-specific st-t wave changes. compared to the previous tracing of qrs change in lead v5 is probably positional. . chest us: findings: limited views of the area of interest in the left scapula by ultrasound were obtained. there is no evidence of fluid collections that would be indicative of an abscess. impression: no fluid collection identified. . cxr: cardiac size is top normal. the cardiac silhouette is accentuated by low lung volumes. the lungs are grossly clear with minimal bibasilar atelectasis. there are no large pleural effusions or pneumothorax. sternal wires are in unchanged position when compared to prior study. the location of the sternal wires and very mild diastasis of the sternotomy are better seen in ct from . . ct torso: ct chest without contrast: the lungs are clear allowing for the limitations of respiratory artifact. the heart and great vessels of the mediastinum are remarkable for severe coronary artery calcification, post-coronary artery bypass. there is no pericardial effusion. there is trace atelectasis at the left base. there are no pleural effusions. there is no pathologic axillary, mediastinal, or hilar adenopathy. ct abdomen without contrast: allowing for the limitations of a non-contrast study and artifact generated from the right arm, the liver, spleen, stomach, adrenal glands, and small bowel loops are normal. there are multiple gallstones within an otherwise normal-appearing gallbladder. the pancreas is nearly entirely fatty replaced, but there is diffuse non- specific inflammatory stranding about the pancreas, which could possibly be secondary to pancreatitis. there is no evidence for pseudocyst. without contrast, enhancement of the pancreas cannot be determined. non-specific stranding is also present about otherwise normal-appearing kidneys, but this is a normal finding given the patient's age. there is no free fluid, free air, or pathologic adenopathy. ct pelvis with contrast: the rectum, sigmoid, large bowel is normal. a rectal tube is in situ. a foley catheter is within a collapsed bladder. there is no free air, free fluid, or pathologic adenopathy. bone windows: the patient is status post median sternotomy. no suspicious lesions are identified. impression: 1. non-specific inflammatory stranding about the pancreas may be secondary to pancreatitis. there is no evidence for pseudocyst. 2. cholelithiasis. . ct of the head without contrast: there is no evidence of mass, hydrocephalus, shift of normally midline structures, infarction, or hemorrhage. the -white matter differentiation is preserved. again noted, ill-defined density in the medulla which is likely artifactual in nature. the osseous and soft tissue structures are unremarkable. the visualized paranasal sinuses are clear. impression: no acute intracranial process. . skull ap&lat/c-sp/cxr/abd slg views mr s: six radiographs involving the skull, thorax and abdomen. no comparison studies. there is no radiopaque foreign bodies that would preclude mri. cavitary fillings are noted as are median sternotomy wires. there is vascular calcification of the soft tissues of the neck. note is made of some minimally dilated loops of small bowel and mild osteoarthritic changes of the hips. impression: 1) no metallic foreign bodies that would preclude mri. 2) minimally dilated loops of small bowel. . orbits pre-mri: no comparison studies. no radiopaque foreign bodies are seen overlying the orbits. multiple fillings are noted. no acute fractures are visualized nor air-fluid levels within the sinuses. impression: no orbital foreign bodies visualized. . lenis: findings: there is normal compression, augmentation, pulse doppler waveform, and color doppler signal within the left and right common femoral, superficial femoral, and popliteal veins. proximal calf veins on the right appear unremarkable by color doppler. the left-sided calf vessels are not well visualized. impression: negative for dvt bilaterally. . mr head w/o contrast: findings: there are no masses, lesions, mass effect, or shift of normally midline structures. the ventricles and sulci are normal in size and configuration. there are no areas of diffusion abnormalities to indicate acute stroke. there are small areas of bilateral periventricular white matter hyperintensities noted on flair sequences and that could reflect age associated microvascular change. impression: no abnormalities to explain patient's cognitive slowing. no evidence of acute stroke. . back ultrasound: findings: there is diffuse edema in the region of the left scapula consistent with site of clinical concern. there is no drainable fluid collection. impression: diffuse edema. no drainable fluid collection. brief hospital course: 62 yo man with history of cad s/p cabg, dm2, htn, sciatica, depression admitted with altered mental status and fever requiring transfer to floor, likely to cellulitis. . # altered mental status: pt initially very lethargic on floor. he was started on vanco and zosyn empirically for one fever to 100.5 with leukocytosis. labs also notable for acute on chronic renal insufficiency, hyperglycemia, and evidence of dehydration. he was transferred to the micu for further care. in the micu, patient was switched to vancomycin and ampicillin pending lp results, which were negative. ua and pending blood and urine cultures were also negative. ct head, cxr, and ct abdomen and pelvis were unremarkable. hiv, rpr, b12, folate, and tsh nl. serum and urine tox were notable only for elevated tca level, but quantitative serum amitriptyline was normal, and pt later denied overdose. he was noted to have an erythematous patch on his left shoulder with satellite lesions extending down left arm concerning for cellulitis, for which patient was maintained only on vanco. also noted to have urinary retention which may have contributed to altered mental status. as pt with no further fevers and initial delirium resolved, patient was transferred back to the floor on . although he was noted to be aao x 3 on the floor, he displayed a tangential thought process with some mystical beliefs. he was evaluated by psych who did not see evidence of active depression recommended continuing to hold outpatient psych meds (amitriptyline and wellbutrin), which were discontinued initially in context of elevated tca. there was a question of acute personality change, but further neuro workup with mri head showed no acute intracranial process. psych determined pt without acute safety issues but recommended close psychiatric follow-up for ongoing problems of disorder and possible overvalued beliefs. . # urinary retention: pt with history of bph and question of elevated tsa on admission. foley placed on admission for urinary retention and noted to have post-obstructive diuresis. failed repeat voiding trial despite being restarted on outpatient terazosin. psa noted to be 7.5. foley reinserted and pt discharged with leg bag, scheduled to follow up with urology in 2 weeks for further evaluation. . # acute renal failure: baseline unclear, appears to be about 1.7-1.8. ddx: pre-renal in setting of dehydration (nausea, vomiting, diarrhea, decreased po intake, post-obstructive diuresis) vs. post-renal in light of urinary retention. improved over hospital course with cr of 1.7 on discharge. outpatient lasix held, to be restarted by pcp as indicated. . # cellulitis: erythematous and edematous with expressible purulent drainage with no evidence of drainable fluid collection on ultrasound, evaluated by dermatology who agreed with diagnosis of cellulitis. initially treated empirically with vanco but switched to 1st generation cephalosporin as wound culture grew out mssa. also given tetanus shot as pt reported development of cellulitis in context of scratching back with metal pasta spoon. discharged with vna for wound care and on keflex, to complete a 14-day antibiotic course. . # prurigo nodularis: pt also noted to have circular lesions with heaped up borders scattered down left arm. evaluated by dermatology and determined to be prurigo nodularis, self-induced by scratching. pt instructed not to touch lesions, attempts made to keep bandaged although pt non-compliant. he was treated with sarna and bactroban and restarted on outpatient hydroxyzine. . # diabetes: hb 6.4. pt started on nph at lower dose as he had decreased po intake during hospitalization. discharged pt on nph 40 units with instructions to check regularly and notify pcp if running low or high for adjustment of insulin dose. benefit from follow-up. . # diarrhea: pt evaluated for diarrhea which was trace guiaic positive. no evidence of infectious etiology. trace guaiac positive stools attributed to irritation of internal hemorrhoids, and diarrhea improved spontaneously during hospitalization and no longer incontinent of bowel. discharged with instructions to try immodium if diarrhea worsened. . # anemia: pt was noted to have microcytic anemia, guaiac on rectal exam and of stools as trace guaiac positive attributed to irritation of internal hemorrhoids seen on colonoscopy last year. iron studies with low iron level but elevated ferritin. pt started on iron supplementation in micu due to mixed picture. pt remained hemodynamically stable with no other signs of active bleed but hct slowly trended down to 29.7 on discharge. would recommend further outpatient monitoring. . # sinus tachycardia: pt monitored on telemetry initially for elevated tca level. heart rate initially in 120s to 130s and sinus. this was thought to persist longer than would be expected if tca effect, and quantitative amitryptiline level added to admission labs later returned normal with negative follow-up tca level. not consistent with alcohol withdrawal. echo unremarkable for valvular disease or abnormal contractility. low suspicion for pe as oxyenating well with no evidence of right heart strain and no dvt on lenis. have component of dehydration from recent nausea/vomiting, diarrhea, as well as post-obstructive diuresis and received ivf. also have had high adrenergic state in context of urinary retention. per pcp, noted to have sinus tachycardia on past visits with hr of 109 at last visit. sinus tachycardia subsequently resolved with hr 80s-90s on discharge, etiology still unclear. . # ?etoh use: pt with history of heavy etoh use although denied current alcohol abuse. however, noted to be perseverative about drinking ginger beer, "which is non-alcoholic." concern for underlying etoh issue in light of sinus tachycardia although ethanol negative on admission and no signs of withdrawal. was started on folate, thiamine, and mvi, which can discontinued by pcp if further evaluation not concerning for etoh abuse. . # non-gap metabolic acidosis: present throughout hospital course but improving on discharge, attributed to diarrhea. . # ?pancreatitis: patient presented with altered mental status, evidence of dehydration with acute on chronic renal failure, ?report of vomiting, elevated lipase, and ct scan with some possible stranding on ct scan although reported to be non-inflammatory. per micu report, pt without clinical evidence of pancreatitis. lipase normalized on transfer to floor and no evidence of abdominal pain during rest of hospital course. . # cad: s/p cabg in . stable, continued on outpatient management. medications on admission: aspirin 81 mg daily amoxicillin 500 mg daily furosemide 20 mg daily budeprion 150 mg daily cozaar 50 mg daily amytriptyline 50 mg daily simvastatin 10 mg daily toprol 200 mg daily terazosin 2 mg daily hydroxyzine 25 mg daily omeprazole 20mg daily prn terbinafine, premethrin, triamcinolone, nitroquick discharge medications: 1. insulin nph human recomb 100 unit/ml cartridge sig: as directed units subcutaneous twice a day: 40 units qam, 40 units qhs. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. metoprolol succinate 100 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po daily (daily). 4. losartan 50 mg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 11. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). 12. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 13. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 6 days. disp:*18 capsule(s)* refills:*0* 14. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day). disp:*1 tube* refills:*2* 15. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. disp:*1 bottle* refills:*0* 16. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po once a day as needed for pruritis. 17. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. capsule(s) discharge disposition: home with service facility: homecare discharge diagnosis: primary - cellulitis - prurigo - sinus tachycardia - diarrhea - anemia - acute on chronic renal failure - urinary retention seconary - hypertension - hypercholesterolemia - diabetes mellitus 2 - cad s/p cabg - bph - h/o depression v. adjustment disorder - gerd - s/p penile implant discharge condition: stable, afebrile. discharge instructions: you were admitted with altered mental status. you were found to have a skin infection (cellulitis) that was treated with antibiotics. you have another rash called prurigo caused by scratching. you were also noted to have a fast heart rate, but there was no abnormality found on various tests, including an echocardiogram. this resolved on its own. your diarrhea is also improving, your anemia is stable, and your kidney function is at baseline. please be sure to stay well hydrated. lastly, you were noted to have urinary retention. you will be discharged with a foley catheter with leg bag and will need to follow up with urology for further evaluation. the following changes were made to your medications: - take keflex for a total of 14 days for cellulitis - use sarna and bactroban for prurigo - take iron for anemia - take thiamine, folate, and multivitamins - take immodium (otc) as needed for diarrhea - amitryptiline and wellbutrin discontinued, restart as instructed by your doctor - lasix discontinued, to be restarted by your doctor. please take all other medications as prescribed. please call masshealth and notify them of your pcp . for billing purposes, the masshealth attending name is dr. . the address is . the phone number is . please call your doctor or come to the ed if you develop fevers > 100.4, confusion, worsening skin infection, abdominal pain, inability to produce urine, chest pain, dizziness, or other concerning symptoms. followup instructions: you are scheduled to see your new pcp at , dr. , on @ 2:30 pm. you will need follow up with with him/her regarding your kidney function, anemia, diabetes control, and cellulitis. your doctor to refer you to see a psychiatrist. he/she may also refer you to a diabetes specialist. please call the clinic at with any questions. you will also need to follow up with urology for further evaluation of your urinary retention. you are scheduled to see dr. das on at 8:30am. until then, you will need to keep your foley catheter in place. please call the office at if you have any questions. procedure: spinal tap incision of lung diagnoses: acidosis esophageal reflux toxic encephalopathy acute kidney failure, unspecified aortocoronary bypass status chronic kidney disease, unspecified hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (luts) other specified cardiac dysrhythmias alkalosis cellulitis and abscess of upper arm and forearm retention of urine, unspecified iron deficiency anemia, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled dehydration lichenification and lichen simplex chronicus hypertensive chronic kidney disease, benign, with chronic kidney disease stage i through stage iv, or unspecified elevated prostate specific antigen [psa] 

Answer: The patient is high likely exposed to