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 70-year-old gentleman with a history of cadaveric renal transplant in , type 2 diabetes, coronary artery disease (status post silent anteroseptal myocardial infarction with a most recent ejection fraction of 40%) who was recently admitted to the surgery service at from to . at this time, he was treated for diverticulitis and acute renal failure secondary to acute tubular necrosis. he had been treated with ampicillin, levaquin, and flagyl and then discharged to rehabilitation. the patient presented to the emergency department on from rehabilitation for decreased systolic blood pressures in the 80s to 90s with acute renal failure and electrocardiogram changes consistent with positive troponins. the patient had never complained of chest pain or shortness of breath. cardiology was curbsided. given that his presumed silent myocardial infarction had occurred about two weeks ago (on the 6th) there was no need for any immediate catheterization and no anticoagulation at this time. it was felt that his hypotension was not secondary to cardiogenic shock given his clinical examination with no pulmonary edema and timing of the events. while the patient was in the emergency department on this admission, the patient's systolic blood pressure ran in the 80s. the patient was given two liters of intravenous fluids, two units of packed red blood cells, with systolic blood pressures responding to the 100s. he was also given 125 mg of solu-medrol given the patient's history of prednisone for immunosuppression and thoughts of possible renal insufficiency. the patient had also been complaining of left lower quadrant pain. an abdominal computed tomography was performed which showed worsening sigmoid diverticulitis. the general surgery team consulted at this time. past medical history: 1. end-stage renal disease; secondary to diabetes to hypertension; status post left cadaveric renal transplant in . 2. acute renal failure; secondary to acute tubular necrosis. 3. hypertension. 4. type 2 diabetes. 5. status post cerebrovascular accident. 6. coronary artery disease; status post recent anteroseptal myocardial infarction (last ejection fraction of 40% in ). 7. status post appendectomy. 8. status post cholecystectomy. 9. sigmoid diverticulitis. 10. cataracts. 11. history of anemia. 12. history of adjustment disorder with depression. allergies: the patient has a questionable allergy to vancomycin (with burning skin); but otherwise no known drug allergies. medications on admission: (his medications on admission included the following) 1. cellcept mg by mouth twice per day. 2. prednisone 7.5 mg by mouth once per day. 3. tacrolimus 1 mg by mouth twice per day. 4. bactrim single strength by mouth three times per week. 5. protonix 40 mg by mouth once per day. 6. aspirin 325 mg by mouth once per day. 7. lipitor 10 mg by mouth once per day. 8. zoloft 50 mg by mouth once per day. 9. flagyl 500 mg by mouth three times per day 10. levaquin 500 mg by mouth once per day. 11. epogen 8000 units twice per week. physical examination on presentation: on admission examination, his vital signs revealed a temperature of 98 degrees fahrenheit, his blood pressure was 97/48, his heart rate was 81, his respiratory rate was 16, and his oxygen saturation was 98% on room air. in general, the patient was morbidly obese individual. he was alert and oriented to person but disoriented to place (thinking rehabilitation) and also to date. in no acute distress. his head, eyes, ears, nose, and throat examination revealed his pupils were equal, round, and reactive to light and accommodation. extraocular movements were intact. the oropharynx was dry. he had no lymphadenopathy, and it was difficult to assess jugular venous distention secondary to his massive neck. cardiovascular examination revealed faint heart sounds. a regular rate and rhythm. pulmonary examination revealed the lungs were clear to auscultation bilaterally. abdominal examination revealed the abdomen was obese, soft, and nondistended. positive bowel sounds. increased tenderness in the left lower quadrant, but no rebound or guarding. he was guaiac-negative in the emergency department. his extremity examination revealed no edema. he was well perfused. pertinent laboratory values on presentation: laboratories on admission revealed his white blood cell count was 10 (with 74% neutrophils and 16% bands), his hematocrit was 26.4 (which had dropped from 34.5), and his platelets were 160. his coagulation studies revealed his prothrombin time was 13, his partial thromboplastin time was 34, and his inr was 1.2. his electrolytes revealed his sodium was 135, potassium was 3.9, chloride was 107, bicarbonate was 16, blood urea nitrogen was 51, creatinine was 3.1 (with baseline of about 1.3 in ), and his blood glucose was 174. his calcium was 7.5, his magnesium was 1.6, and his phosphate was 4.3. the patient's troponin levels were 3.5 and 2.9. his creatine kinase levels were 643 and 551. his mb fraction levels were 6 and 7. his urinalysis showed small amount of blood, up to 20 white blood cells, 30 protein, small amount of bacteria. his laboratory work from rehabilitation showed a worsening creatinine from to from a creatinine of 1.2 on to 3.5 on . his hepatitis a and hepatitis b panels were negative. pertinent radiology/imaging: a chest x-ray revealed mild congestive heart failure with atelectasis at the right base and a right subclavian line which was confirmed to be in the proper place. electrocardiogram on admission revealed a normal sinus rhythm at 85 beats per minute. there were q waves in v1 and v2 with 1-mm st elevations in v2 and v3, and t wave inversions in leads v4 through v6. compared with electrocardiogram from which showed marked st elevations in leads v1 through v3. he had a computed tomography on admission which showed (as mentioned above) worsening sigmoid diverticulitis, with small pleural effusions, and atelectasis. brief summary of medical intensive care unit course: the medical intensive care unit course can briefly be summarized as follows. the patient was admitted for hypotension, and acute renal failure, and also acute sigmoid diverticulitis. he had a computed tomography, as mentioned above, which showed worsening sigmoid diverticulitis. he was maintained on bowel rest, and made nothing by mouth, and was started on empiric antibiotic therapy with intravenously unasyn. meanwhile, in terms of his cardiovascular issues, cardiology felt there was no need for acute intervention in terms of a catheterization or heparinization given that his cardiac event had likely occurred two weeks ago. he did have an echocardiogram which was significant for showing a severely depressed left ventricular function with resting wall motion abnormalities in the anteroseptal and apical regions with akinesis and dyskinesis without any evidence of thrombus and an ejection fraction estimated at 25% to 30%. meanwhile, his acute renal failure was thought to be secondary to acute tubular necrosis; possibly secondary to hypotension. his creatinine continued to improve during his medical intensive care unit admission, and the patient was transferred to the floor on . concise summary of hospital course by issue/system: the remainder of the hospital course was extremely complicated involving several medical intensive care unit stays, and this will be dictated by system. 1. cardiovascular issues: the patient had come transferred from rehabilitation after he was believed to have suffered a massive silent st-elevation myocardial infarction in the anteroseptal region. he came in hypotensive thought mainly not secondary to cardiogenic shock but rather secondary to a possible sepsis with diverticulitis. he had an echocardiogram on admission which did show markedly depressed left ventricular function with an ejection fraction of 20% to 25% compared with the most recent echocardiogram from which revealed an ejection fraction of 40%. given that this ischemic event had occurred about two weeks prior to his admission, it was felt by cardiology it would be reasonable to withhold any more aggressive intervention in terms of cardiac catheterization and heparinization at this time. rather, he was continued on aspirin, continued on a statin, and started on low-dose metoprolol as his blood pressures tolerated. on the floor, cardiology was again consulted after several days, the patient's blood pressures had improved, for further evaluation of the possible need for catheterization. they had recommended performing a persantine thallium to assess myocardial viability which showed severe fixed defects of the distal, anterior, and inferior walls, and apex, and apical portions of the septal wall with minimal improvement in the perfusion of the inferior wall, representing minimal to mild cardiac viability with an ejection fraction now of only 16%. at that point, it was decided to defer a cardiac catheterization until a later date. meanwhile, the patient continued to be medically managed. his beta blocker was increased as his blood pressures tolerated, and he was started on an ace inhibitor, as well as his blood pressures could tolerate. he was maintained on a statin. there was no evidence of any other active ischemic changes during the hospital course on the medical . he had several enzymes levels checked periodically which did show a mildly elevated troponin levels, but this was thought to be possibly secondary to the patient's renal failure. regarding congestive heart failure, as a result of his massive ischemic event the patient had a markedly decreased ejection fraction of 15%. when he had come in, he was not thought to be in acute congestive heart failure; and rather was just maintained on a beta blocker and ace inhibitor as his blood pressures tolerated. cardiology had recommended, given his low ejection fraction, that the patient be anticoagulated to reduce the risk of left ventricular thrombus formation. therefore, the patient was heparinized and then eventually transferred over to coumadin. during his hospital course, on the , it was felt that the patient began to fall into mild congestive heart failure with increased respiratory distress thought secondary to the congestive heart failure. as such, he diuresed quite aggressively with intravenous lasix but still with difficulty in adequately diuresing the patient and keeping him negative. there had been talk of possibly transferring him to an additional floor for possible nesiritide, but it was instead felt that the patient still had room, in terms of his renal function, to be increasing diuresed with higher doses of intravenous lasix. he was maintained on an ace inhibitor (lisinopril) and low-dose coreg as his blood pressures tolerated; which sometimes was difficult to assess given the patient's large size, and the patient with frequent in his blood pressures; so it was difficult to very aggressively titrate these medications. regarding his cardiac rhythm, as a result of the patient's severely depressed ejection fraction to 15% to 20% by persantine thallium, the patient was thought to be at an increased risk for sudden death secondary to a fatal cardiac arrhythmia. while on the floor, he had in fact had several runs of nonsustained ventricular tachycardia. at this point, electrophysiology had been consulted, and they had initially recommended the placement of an implantable cardiac defibrillator for this patient. in the interim period, it was recommended that the patient be loaded up with amiodarone to suppress possible increased ventricular ectopy and runs on nonsustained ventricular tachycardia. amiodarone was in fact started on the patient, and the patient was maintained on telemetry but was able to avoid significant runs of nonsustained ventricular tachycardia. at the time of this dictation, the implanted cardiac defibrillator will be deferred until the patient's more acute health issues are addressed; namely, he now recent stay in the surgical intensive care unit for diverticulitis which will be dictated at a later date. in addition to his nonsustained ventricular tachycardia, which was controlled with amiodarone, the patient at times was found to be in and out of atrial fibrillation. the patient remained rate controlled on the low-dose beta blocker and continued to be anticoagulated secondary to his low ejection fraction. 2. hemodynamic issues: regarding his hemodynamic standpoint, the patient had come in initially wit hypotension secondary to sepsis. following his first medical intensive care unit stay, his blood pressures had improved to the point where back on the floor he was able to tolerate a low-dose ace inhibitor and a beta blocker. on the morning of , the patient again was found to be hypotensive and febrile and was transferred to the medical intensive care unit for likely sepsis. the patient had been found with a decreased hematocrit and was thought to have been bleeding from an unclear source. after several days in the medical intensive care unit, his hematocrit improved, status post transfusions of several units of packed red blood cells, and the patient was transferred to the floor and remained hemodynamically stable up until his most recent transfer to the medical intensive care unit which will be dictated at a later date. 3. pulmonary issues: as mentioned above, the patient came in with a markedly depressed left ventricular function secondary to a massive ischemic event that he suffered during rehabilitation as an outpatient. as a result, the patient had severe congestive heart failure with an ejection fraction of 15% to 20%. during the majority of his hospital stay on the , the patient was found with labored breathing, paradoxical breathing, although was able to maintain adequate saturations to the mid 90s on several liters of fluid. it was thought by chest x-rays that the patient's labored breathing was most likely secondary to volume overload, and the patient's respiratory status would be improved with aggressive diuresis. as such, the patient was diuresed with a goal of one liter negative per day with increasing amounts of intravenous lasix. however, this was difficult to achieve. throughout the patient's stay he remained slightly tachypneic but stable with oxygen saturations in the mid 90s on several liters of oxygen. again, all thought secondary to volume overload and congestive heart failure. he would later be intubated secondary to increased hypotension and hypoxia during his third medical intensive care unit stay during this admission which will be dictated at a later date; starting on . 4. gastrointestinal issues: the patient has a history of sigmoid diverticulitis. initially, the patient had recently been discharged from the in early for this issue. then, on admission to on , the patient was found to be with worsening sigmoid diverticulitis. given his multiple comorbidities; namely, his ischemic heart disease and congestive heart failure, it was decided to medically manage the patient by the surgery team. so, the patient was given bowel rest with total parenteral nutrition. the patient was started empirically on unasyn which was later switched to zosyn and at a later date levaquin and flagyl. he had a follow-up computed tomography on following his second medical intensive care unit stay for hypotension and fevers, presumed sepsis, thought possibly secondary to his known diverticulitis. however, this computed tomography showed in fact improving diverticulitis. the patient had a subsequent computed tomography on which again showed markedly improved sigmoid diverticulitis compared with previous studies. by this time, the surgical team had signed off on the patient as the patient had been stable in terms of issues of diverticulitis for some time. infectious disease was consulted to determine the duration of antibiotic treatment for this diverticulitis, as the patient had been broad spectrum antibiotics for over one month. based upon the improved computerized axial tomography from , and the fact that the patient had negative blood cultures off antibiotics from and all of his previous blood cultures had been negative, infectious disease felt comfortable about discontinuing his antibiotics for his diverticulitis. meanwhile, the patient had originally been by mouth and had been started on total parenteral nutrition for bowel rest during the period of active diverticulitis (per surgery recommendations). after several days on the floor, the patient was started on tube feeds and later had passed a swallowing study and began to take oral intake without feeding tubes. later on during the hospital course, it was felt that the patient was not taking in the amount of calories that were needed to help him recover from the severe illness that he had been dealing with, in terms of the nutrition team, he needed to recuperate and heal the wounds that he needed. discussions were held with the family, and it was decided to place a percutaneous endoscopic gastrostomy tube that would allow for increased and consistent nutrition during his hospital course. this percutaneous endoscopic gastrostomy tube was placed without any complications, and the patient was restarted on tube feeds through the percutaneous endoscopic gastrostomy tube and encouraged to take oral intake in addition to this. there were no other active gastrointestinal issues during the patient's stay on the floor. he was maintained on protonix for gastrointestinal prophylaxis since he was known to have guaiac-positive stools. plus, his hematocrit remained stable following his second brief admission to the intensive care unit for a decreased hematocrit of unclear source. so, as mentioned above, his diverticulitis had resolved off of antibiotics, and the patient was stable on percutaneous endoscopic gastrostomy tube feeds up until his third medical intensive care unit stay which will be dictated at a later date for increased fevers and hypotension. 5. hematologic issues: the patient came in with a history of anemia (on epogen) possibly secondary to his renal disease. during his initial hospital stay, he was transfused several units of packed red blood cells which helped with his systolic blood pressures. during the majority of his stay in the hospital , the patient's hematocrit remained stable in the low 30s. he had an episode of hypotension with 7-point or 8-point drop in his hematocrit on (as dictated above0, which required a second medical intensive care unit stay. the patient was transfused several units of packed red blood cells, and there was no clear source of this drop in his hematocrit. the patient's hematocrit remained stable during the remainder of his course on the medicine . he was started on anticoagulation (as dictated above) secondary to his depressed ejection fraction and the risk for left ventricular thrombi, and there were no other hematologic issues during this hospital stay. of note, the patient had been found with increased right upper extremity edema worrisome for possible deep venous thrombosis. however, on several occasions, the patient had negative doppler ultrasounds. this upper extremity edema was thought secondary to a low albumin and patient positioning. 6. infectious disease issues: the patient came in thought septic and hypotensive secondary to worsening diverticulitis. all of his blood cultures during his hospital course have remained negative. he was initially empirically started on unasyn for treatment of his diverticulitis then changed to zosyn. general surgery had been following initially for medical management of his diverticulitis. upon transfer to the floor, the patient was maintained on zosyn. prior to his second medical intensive care unit stay, the patient had spiked fevers and there was concern about adding additional gram-negative coverage. so, briefly, ciprofloxacin had been started, and vancomycin had been started to rule out any possible nosocomial-type pneumonia that could have been causing his fevers. following his second stay in the medical intensive care unit, the patient was maintained on zosyn and flagyl for broad anaerobic coverage and then later switched to levofloxacin and flagyl. per infectious disease recommendations, these antibiotics were discontinued toward the end of his hospital stay on the secondary to markedly improving diverticulitis as evidenced by his recent computerized axial tomography on . meanwhile, the patient was found with persistent yeast in his urine thought secondary to several risk factors including foley, broad spectrum antibiotics, and his diabetes. he had previously had several courses of fluconazole, but still with difficulty in eradicating the yeast. at this point, it was felt that it would be reasonable to withhold additional fluconazole unless the patient developed fevers or white blood cell count which had not been the case on the hospital . meanwhile, he had been evaluated by plastic surgery and later podiatry for worsening sacral decubitus ulcerations and foot ulcerations. podiatry had initially recommended placing the patient in multipoultice boots for treatment of a left heel ulceration which subsequently did not improve with this treatment. further evaluation from podiatry on the 20th recommended possibly repeating a magnetic resonance imaging and beginning antibiotics of zosyn, as there was concern that the ulceration may have been infected. there were no other infectious disease issues during the patient's hospitalization course. 7. renal issues: the patient was status post cadaveric renal transplant in and came in with acute renal failure thought secondary to acute tubular necrosis with an elevated creatinine to 3.1 and 3.2. these creatinine levels dropped during the medical intensive care unit stay, and by the time the patient was on the floor had creatinine levels which were stable in the low 1 range; ranging anywhere from 1 to about 1.3 to 1.4. the patient was followed by the renal team for continued immunosuppression given his recent transplant. he was maintained on cellcept, tacrolimus, and prednisone as part of his immunosuppression. he was also continued on bactrim three times per week; also associated with his regimen. as mentioned earlier in the cardiovascular and pulmonary sections, it was felt that during the majority of the hospital course on the , he was in fact volume overloaded and that the patient would benefit from aggressive diuresis. as mentioned above, the patient was diuresed with increasing amounts of intravenous lasix unsuccessfully to try to remove some of this excess fluid that was thought to be causing respiratory distress. also, as mentioned above, the patient had difficulty in eradicating persistent yeast from his urine which was thought secondary to persistent broad spectrum antibiotics and foley catheters. as mentioned above, given the fact that the patient had not been spiking fevers and was not septic, it was thought reasonable to hold off on additional treatment for his persistent candiduria. 8. endocrine issues: the patient came in with poorly controlled diabetes. he was followed by the clinic during his hospital stay for management with his persistently elevated blood sugars. initially, in the evening, his blood sugars were well controlled in the intensive care unit on an insulin drip and was transferred over to the floor with varying regimens of nph sliding-scales and later lantus as he had started tube feeds; which showed some improvement with his blood sugars in the low 200s. upon his third transfer to the intensive care unit, he was again started on an insulin drip with complete blood sugar control. 9. psychiatric/neurologic issues: the patient had come in with a history of an adjustment disorder and depression. as his hospital course persisted, it was felt that the patient had become increasingly depressed which was thought to be inhibiting his recovery from his acute illnesses. psychiatry was consulted for further evaluation who were also concerned about possible delirium/dementia in addition to depression. a head computed tomography was obtained which was negative for any acute strokes or hemorrhages; but this did show some encephalomalacia and atrophy at the left frontal lobe. per psychiatry, the patient was started and titrated up to zoloft with the present dose being 100 mg by mouth once per day and was also started dexamphetamine for possible stimulation while his cardiac rhythm was monitored, which remained stable despite these cardiostimulant drugs. note: this marks the end of this dictation for the hospital course at this time. there will be additional dictations made for the patient's most recent course in the surgical intensive care unit following his most recent episode of sepsis and abdominal surgery. , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy open and other sigmoidectomy permanent colostomy other myectomy other immobilization, pressure, and attention to wound injection or infusion of nesiritide diagnoses: acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified septicemia perforation of intestine systolic heart failure, unspecified hypotension, unspecified complications of transplanted kidney diverticulitis of colon (without mention of hemorrhage) 

Answer: The patient is high likely exposed to