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: codeine / enalapril attending: chief complaint: hemodialysis line not working major surgical or invasive procedure: balloon angioplasty and tunneled catheter placement peritoneal dialysis catheter placement history of present illness: 50 year old man with history of end stage renal disease secondary to amyloidosis, paroxysmal atrial fibrillation, type 2 diabetes on insulin admitted after his hemodialysis line was found to be not working halfway through his hemodialysis session today. because of his history of hyperkalemia, it was not felt to be safe to return him to his nursing home without access. he has been admitted to the hospital for monitoring and for resolution of his access problem. in the ed, his vital signs were: 97.9 92 110/60 18 98% ra. he had no complaints. he was seen by nephrology, who left recommendations in the chart and asked that he not be given any prophylactic heparin given his history of bleeding. past medical history: esrd secondary to amyloidosis -failed lrrt in now on hemodialysis (right groin line) inferior vena cava stent sarcoidosis pulmonary aspergillosis - on chronic voriconazole type 2 diabetes, on insulin chronic hepatitis c hypertension sinusitis paroxysmal atrial fibrillation, clostridium difficile mrsa line sepsis renal osteodystrophy adrenal insufficiency upper extremity deep vein thrombosis () pancreatitis bilateral below the knee amputation right index and fifth finger amputations allerties: enalapril--pancreatitis codeine--lightheadedness primary care physician: social history: smoked 1 pack per day x 30 years but quit 3 months ago. + history of alcohol abuse, but stopped 4 years ago. previous drug use with cocaine (+iv drug use), has been clean since about . girlfriend is involved in his care. lives in a care home in . mother lives nearby. family history: mother, brother with diabetes. no h/o kidney disease physical exam: (on admission per dr. 98.0 93/61 104 24 pleasant, frail man in nad. breathing comfortably. eomi, slight redness to his right corneal membrane. op clear, mm dry. neck supple. s1, s2, rrr (not tachy to my exam), systolic murmur at lusb and at apex. lungs clear b/l but with poor air movement throughout. abd soft, nt, nd. +bs right femoral catheter clean, dry, no erythema or induration. b/l bka well healed, skin somewhat dry. no edema. missing digits of his hands. pleasant, answers questions appropriately but does not have impressive knowledge of his medications or medical history. pertinent results: 03:40pm blood wbc-8.6 rbc-5.09# hgb-14.9# hct-48.9# mcv-96 mch-29.3 mchc-30.4* rdw-17.3* plt ct-438# 08:15am blood wbc-12.8* rbc-4.77 hgb-14.0 hct-45.5 mcv-95 mch-29.3 mchc-30.8* rdw-17.3* plt ct-451* 06:50am blood wbc-10.4 rbc-4.82 hgb-14.2 hct-46.3 mcv-96 mch-29.4 mchc-30.6* rdw-18.6* plt ct-463* 12:21pm blood wbc-10.8 rbc-3.94* hgb-11.9* hct-38.8* mcv-98 mch-30.2 mchc-30.6* rdw-18.9* plt ct-327 01:50am blood wbc-9.8 rbc-3.65* hgb-10.8* hct-34.8* mcv-95 mch-29.5 mchc-31.0 rdw-17.8* plt ct-276 04:50pm blood hct-39.5* 05:51am blood wbc-11.8* rbc-3.62* hgb-10.6* hct-35.7* mcv-99* mch-29.2 mchc-29.6* rdw-17.9* plt ct-206 03:00am blood wbc-8.9 rbc-3.51* hgb-10.4* hct-33.8* mcv-96 mch-29.6 mchc-30.7* rdw-17.6* plt ct-212 04:39am blood wbc-8.0 rbc-3.70* hgb-11.2* hct-35.6* mcv-96 mch-30.4 mchc-31.6 rdw-18.1* plt ct-224 11:45am blood wbc-7.6 rbc-3.67* hgb-10.7* hct-34.9* mcv-95 mch-29.3 mchc-30.8* rdw-17.2* plt ct-256 08:40am blood wbc-7.7 rbc-3.64* hgb-10.8* hct-34.9* mcv-96 mch-29.5 mchc-30.8* rdw-16.8* plt ct-274 06:45am blood wbc-8.5 rbc-3.70* hgb-10.8* hct-35.6* mcv-96 mch-29.2 mchc-30.4* rdw-16.9* plt ct-278 04:46am blood wbc-9.8 rbc-3.62* hgb-10.6* hct-35.1* mcv-97 mch-29.2 mchc-30.1* rdw-16.7* plt ct-358 07:55am blood wbc-8.0 rbc-3.86* hgb-11.4* hct-37.2* mcv-97 mch-29.5 mchc-30.6* rdw-17.8* plt ct-352 07:35am blood wbc-9.4 rbc-3.75* hgb-10.8* hct-37.4* mcv-100* mch-28.7 mchc-28.7* rdw-16.6* plt ct-426 07:55am blood wbc-6.4 rbc-3.81* hgb-10.9* hct-38.3* mcv-101* mch-28.7 mchc-28.6* rdw-16.6* plt ct-348 05:45am blood wbc-7.1 rbc-3.79* hgb-11.0* hct-37.3* mcv-98 mch-29.0 mchc-29.5* rdw-17.4* plt ct-388 08:20am blood wbc-8.6 rbc-4.01* hgb-11.6* hct-39.7* mcv-99* mch-28.8 mchc-29.1* rdw-16.6* plt ct-549* 03:40pm blood neuts-77.2* lymphs-16.5* monos-5.6 eos-0.5 baso-0.2 06:50am blood neuts-62.1 lymphs-26.0 monos-10.2 eos-0.9 baso-0.7 . 08:15am blood pt-14.1* ptt-31.2 inr(pt)-1.2* 11:00pm blood pt-14.2* ptt-62.1* inr(pt)-1.2* 12:21pm blood pt-13.3 ptt-35.5* inr(pt)-1.1 01:50am blood pt-12.6 ptt-56.8* inr(pt)-1.1 05:51am blood pt-14.0* ptt-56.7* inr(pt)-1.2* 06:30pm blood pt-14.0* ptt-74.7* inr(pt)-1.2* 03:00am blood pt-13.9* ptt-64.5* inr(pt)-1.2* 12:00pm blood pt-14.4* ptt-150.0* inr(pt)-1.3* 04:39am blood pt-13.6* ptt-40.2* inr(pt)-1.2* 02:30pm blood pt-13.9* ptt-39.9* inr(pt)-1.2* 02:00am blood pt-13.7* ptt-51.6* inr(pt)-1.2* 11:45am blood pt-13.8* ptt-62.9* inr(pt)-1.2* 09:43pm blood ptt-55.8* 04:30pm blood ptt->150* 08:55pm blood pt-13.4 ptt-36.8* inr(pt)-1.1 11:32pm blood pt-13.7* ptt-33.8 inr(pt)-1.2* 06:45am blood pt-14.0* ptt-42.6* inr(pt)-1.2* 05:45am blood pt-13.8* ptt-28.2 inr(pt)-1.2* . 03:40pm blood glucose-132* urean-27* creat-6.2* na-134 k-3.9 cl-100 hco3-17* angap-21* 08:15am blood glucose-88 urean-39* creat-8.3*# na-138 k-4.2 cl-101 hco3-17* angap-24* 01:50pm blood glucose-76 urean-42* creat-8.4* na-135 k-4.6 cl-100 hco3-16* angap-24* 06:50am blood glucose-102 urean-57* creat-9.7*# na-136 k-5.7* cl-100 hco3-17* angap-25* 12:21pm blood glucose-82 urean-27* creat-6.5*# na-141 k-4.8 cl-109* hco3-18* angap-19 01:50am blood glucose-87 urean-31* creat-7.5* na-138 k-5.3* cl-105 hco3-18* angap-20 05:51am blood glucose-90 urean-21* creat-5.5*# na-139 k-4.2 cl-104 hco3-24 angap-15 03:00am blood glucose-83 urean-32* creat-7.0*# na-140 k-4.7 cl-104 hco3-19* angap-22* 04:39am blood glucose-74 urean-18 creat-5.2*# na-139 k-4.0 cl-102 hco3-25 angap-16 11:45am blood glucose-57* urean-37* creat-7.2*# na-139 k-4.0 cl-101 hco3-23 angap-19 08:40am blood glucose-95 urean-25* creat-5.5*# na-140 k-3.0* cl-102 hco3-24 angap-17 06:45am blood glucose-78 urean-27* creat-6.2* na-139 k-4.5 cl-105 hco3-22 angap-17 04:46am blood glucose-69* urean-32* creat-6.6* na-140 k-4.1 cl-105 hco3-21* angap-18 07:55am blood glucose-81 urean-22* creat-5.5*# na-142 k-4.4 cl-106 hco3-24 angap-16 07:35am blood glucose-77 urean-32* creat-6.6*# na-138 k-5.2* cl-103 hco3-21* angap-19 07:55am blood glucose-62* urean-23* creat-5.0*# na-142 k-4.6 cl-110* hco3-20* angap-17 05:45am blood glucose-64* urean-38* creat-6.5*# na-138 k-4.6 cl-106 hco3-19* angap-18 08:20am blood glucose-64* urean-55* creat-8.0*# na-138 k-5.3* cl-104 hco3-17* angap-22* . 07:35am blood alt-6 ast-23 alkphos-167* totbili-0.3 . 08:15am blood calcium-11.3* phos-8.0* mg-2.9* 01:50pm blood albumin-3.5 calcium-11.0* phos-7.8* mg-3.6* 06:50am blood calcium-11.3* phos-8.8* mg-3.1* 12:21pm blood calcium-9.5 phos-7.7* mg-2.9* 01:50am blood calcium-9.9 phos-9.8*# mg-2.1 05:51am blood calcium-10.0 phos-7.8*# mg-1.8 03:00am blood calcium-9.2 phos-9.3* mg-2.0 04:39am blood calcium-9.1 phos-5.8*# mg-1.9 11:45am blood calcium-9.6 phos-7.6*# mg-2.2 08:40am blood albumin-3.4 calcium-9.5 phos-4.7*# mg-2.0 06:45am blood calcium-10.6* phos-6.2* mg-2.3 04:46am blood calcium-10.3* phos-6.3* mg-2.3 07:55am blood calcium-10.1 phos-5.0* mg-2.2 07:35am blood albumin-3.2* calcium-10.2 phos-7.9*# mg-2.3 07:55am blood calcium-9.2 phos-4.7*# mg-2.0 05:45am blood calcium-9.4 phos-6.1* mg-2.3 08:20am blood calcium-9.6 phos-7.2* mg-2.6 . 01:00pm blood pth-628* . 07:19am blood ph-7.31* comment-green . 03:55pm blood glucose-122* k-3.8 09:27pm blood glucose-105 lactate-1.2 na-142 k-3.5 cl-109 calhco3-22 . 09:27pm blood hgb-14.2 calchct-43 07:19am blood freeca-1.33* . wound culture (final ): escherichia coli. >15 colonies. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ 4 s trimethoprim/sulfa---- =>16 r . blood culture x 2 () - no growth blood culture and - no growth to date . ekg () - sinus rhythm. possible biatrial abnormality. compared to the previous tracing of there is no significant change. . fluoroscopic guided removal/replacement of hd catheter (): 1. findings compatible with ivc thrombosis, may be chronic in nature. findings concerning for right atrial thrombus. 2. successful removal of a right femoral tunneled dialysis catheter. triple- lumen 9 french central line placement. 3. secondary to extensive thrombus burden, placement of dialysis catheter was not accomplished. transhepatic placement of hemodialysis catheter can be attempted, when the patient is clinically stable and can tolerate the procedure. . angioplasty, tunneled hd (r femoral) catheter placment, midline placement (): 1. successful balloon angioplasty of the ivc with 8, 12 and 14-mm balloons. 2. followup venogram demonstrated good angiographic result. 3. successful placement of a 55 cm 15.5-french double-lumen dialysis line with tip at the right atrium and the line is ready for use. 4. successful placement of a double-lumen lumen picc line via the right brachial vein with tip at the level of the axillary vein. the line is ready for use. . echocardiogram: the left atrium is normal in size. no mass or thrombus is seen in the right atrium or right atrial appendage. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 70%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is no mitral valve prolapse. there is moderate thickening of the mitral valve chordae. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. the proximal inferior vena cava up to the junction with the right atrium is filled with echodensity consistent with thrombus. however, the echodensity does not appear to extend into the right atrium itself. compared with the findings of the prior study (images reviewed) of , echodensities in the inferior vena cava are now seen. brief hospital course: 50 year old man with history of end stage renal disease secondary to amyloidosis, paroxysmal atrial fibrillation, type 2 diabetes on insulin admitted for dysfunction of hemodialysis line, transferred to icu for hypotension after hemodialysis (3kg taken off) and fentanyl during interventional radiology procedure to declot and replace hemodialysis line. . # end stage renal disease: - last hemodialysis , right femoral tunneled catheter functioning well - renal to attempt to clear catheter with local tpa failed -> interventional radiology for catheter change -> hypotension, extensive clot burden in right femoral vein through inferior vena cava up to right atrium -> icu - dialysis catheter tip growing e. coli, sensitive to ceftazidime, received 1g qhd for 2 weeks after catheter removed, last dose given in in dialysis - right groin catheter in place functioning for now - sevelamer, cinacalcet, nephrocaps - family meeting , decided on placement of peritoneal dialysis and placement of patient in facility that could perform peritoneal dialysis. - status post peritoneal dialysis catheter placement , needs 2-3 weeks to heal prior to use, renal doctor as outpatient. . # finger ischemia: consistent with history of extensive microvascular disease. no anticoagulation - see rationale below. - status post plastic surgery consult - appreciate input - no surgery for now, awaiting demarcation, finger segment will likely autoamputate. no signs of infection necessitating amputation during this hospitalization. . # thrombosis: - extensive inferior vena cava burden to level of right atrium and likely involvement of superior vena cava. risk associated with anticoagulation in this patient related to history of hemodynamically signficant epistaxis, recurrent epistaxis, and hemoptysis related to fungal lesion in left upper lobed of the lung. - maintained active type and screen in blood bank - heparin gtt was started after extensive clot discovered, stopped given epistaxis, possible hemoptysis vs. swallowed blood, peri-catheter oozing . patient hemodynamically stable. hematocrit 34.9->36.7 (dialysis in between draws). will not anticoagulate now after discussing risks and benefits in family meeting on . . # leukocytosis: - no fevers and no signs or symptoms to suggest infection. - wbc 12.8 early in hospital course, now no elevation in wbc - treated for e. coli sepsis after grew on hd cath tip with ceftazidime as above - blood cultures 4/30 - no growth (final) - blood cultures 5/10, pending - were drawn after mildly hypotensive following dialysis, had no fever/wbc elevation . # hypotension & tachycardia: most likely due to fluid removal from dialysis + fentanyl. sepsis also in ddx, especially with leukocytosis. considered bleeding while on heparin gtt, adrenal insufficiency given chronic steroids for sarcoidosis. - hemodialysis end goal weight increased - blood cultures 4/30 - no growth (final) - triggered for bp 60/doppler -> 80s systolic after 1.5l, no signs of active bleeding, mentating at baseline, hematocrit stable - morphine discontinued as likely contributed to hypotension - now oxycodone for finger pain - still mildly hypotenisve post-hemodialysis, asymptomatic, pressure responds to iv fluids . # sarcoidosis: - on chronic prednisone . # pulmonary aspergillosis: - on chronic suppressive voriconazole . # h/o mrsa bacteremia: - no evidence of active infection - continue ds bactrim x 4 with hd for suppressive therapy - followed by as outpatient . # paroxysmal atrial fibrillation: - metoprolol 12.5 mg po 2x/day for rate control as outpatient, had been held in setting of hypotension -> restarted am (held for systolic < 100) - initially no anticoagulation given history of bleeds -> started heparin gtt with discovery of extensive thrombosis -> heparin discontinued given mild nosebleed/hemoptysis/ooze from femoral catheter . # type 2 diabetes - continued glargine at 8 units hs with ssi - fingersticks good range when eating, hypoglycemic when npo for catheter placement . # possible asthma: on albuterol prn . # recent nosebleeds: - per ent consult on last admission, humidified air as much as possible, nasal saline spray q2h, bacitracin to each nostril and massage gently for a few seconds qam and qhs. - epistaxis precautions, including no straining, nose blowing, or temperature hot foods. light activity only. colace or other stool softener on a regular basis. . # constipation: standing colace, senna, dulcolax (made standing ); prn lactulose added -> had bowel movement . # gerd: ppi . # fen: renal, diabetic, low potassium diet . # ppx: ppi, bowel regimen, held anticoagulation . # code: full (confirmed with patient) medications on admission: albuterol nebs b complex-vitamin c-folic acid cinacalcet 30mg daily glargine 8 units hs lispro ssi qid metoprolol 12.5mg omeprazole 20mg daily prednisone 5mg daily, 2.5mg qhs sevelamer 800mg tid bactrim 800mg-160mg 4 tablets after each hd voriconazole 200mg q12h acetaminophen prn docusate 100 prn senna prn bacitracin to prevent nosebleeds oxymetazoline 0.05% spray prn nosebleed sodium chloride aerosol to prevent nosebleeds discharge medications: 1. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) nebulizer inhalation q4h (every 4 hours) as needed for shortness of breath. 2. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for systolic blood pressure < 100, heart rate < 60. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 4. prednisone 5 mg tablet sig: one (1) tablet po every morning. 5. prednisone 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: four (4) tablet po qhd (each hemodialysis): to be given prior to dialysis. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical (2 times a day) as needed for to prevent nosebleeds. 11. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day) as needed for nosebleeds. 12. voriconazole 200 mg tablet sig: one (1) tablet po q12h (every 12 hours). 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: do not exceed 2g in a 24 hour period. 14. lantus 100 unit/ml cartridge sig: eight (8) units subcutaneous at bedtime: and sliding scale as indicated on printout. 15. sevelamer hcl 800 mg tablet sig: three (3) tablet po tid w/meals (3 times a day with meals). 16. insulin glargine 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. 17. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po bid (2 times a day) as needed for constipation. 18. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 19. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 20. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 21. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day). 22. cinacalcet 30 mg tablet sig: three (3) tablet po daily (). discharge disposition: extended care facility: discharge diagnosis: e coli septicemia, catheter related bloodstream infection ivc thrombosis chronic kidney disease stage 5 epistaxis, hemoptysis finger gangrene, peripheral arterial disease secondary diagnoses: sarcoidosis, amyloidosis, pulmonary aspergillosis, paroxysmal atrial fibrillation discharge condition: afebrile with stable vital signs. functioning hd catheter. discharge instructions: you were admitted when you hemodialysis line was found to be clogged. while here, you were found to have extensive blood clot in the veins from the catheter up to your heart. the veins were opened in order to place another catheter. the initial catheter was infected and you were treated with antibiotics for the infection. you received blood thinners for a time after the clots were found, but because of nosebleeds and bleeding from your catheter site, the heparin was stopped. the care team together with you and your family decided that the risk of bleeding was too high to continue. you had a peritoneal dialysis catheter placed while you were here. it will take weeks until this heals and can be used. until then, you will receive hemodialysis through the current line. your left pinky finger became ischemic, there were no signs of infection and it will likely fall off on its own. you should follow up in the hand clinic. - call your doctor or return to the hospital if you experience chest pain, trouble breathing, fevers/chills, inability to eat, severe abdominal pain, foul smelling drainage or pus from your finger or your catheter sites. - continue your dialysis at in as scheduled until you are receiving peritoneal dialysis followup instructions: please continue to follow-up with your nephrologist and with your dialysis treatments. if you develop foul smelling discharge or drainage/pus from your ischemic finger, you can follow up at the hand clinic, the phone number is (. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified hemodialysis angioplasty of other non-coronary vessel(s) injection or infusion of thrombolytic agent venous catheterization for renal dialysis incision with removal of foreign body or device from skin and subcutaneous tissue angiocardiography of venae cavae creation of cutaneoperitoneal fistula procedure on single vessel diagnoses: chronic kidney disease, stage v nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere chronic hepatitis c without mention of hepatic coma diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled atrial fibrillation sarcoidosis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease constipation, unspecified infection and inflammatory reaction due to other vascular device, implant, and graft kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure glucocorticoid deficiency septicemia due to escherichia coli [e. coli] atherosclerosis of native arteries of the extremities with gangrene below knee amputation status epistaxis mechanical complication of other vascular device, implant, and graft aspergillosis hypotension of hemodialysis other venous embolism and thrombosis of inferior vena cava other amyloidosis 

Answer: The patient is high likely exposed to