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: mr. is a 66 year old male with a history of diabetes mellitus, chronic atrial fibrillation, morbid obesity, restricted lung disease, gastroesophageal reflux disease, renal insufficiency, hypothyroidism, obstructive sleep apnea and ventricular tachycardia status post pacemaker defibrillator, who was admitted to an outside hospital on , ten days before admission to for severe leg pain and bilateral necrotic leg ulcers. the outside hospital felt that these leg ulcers were secondary to either ischemic vasculitis or diabetes mellitus. the patient, at the outside hospital, was started on intravenous steroids and transitioned to p.o. steroids after several days. while on steroids, his bun began to rise from 140 to 220. with dose changes in diuretics, his bun came down to 190 and creatinine down to 3.8. also at the outside hospital, his inr got elevated; this was felt secondary to antibiotics given to him for a possibility of cellulitis. it corrected with vitamin k. at the outside hospital he had been followed by rheumatology, dermatology and nephrology. there was discussion regarding dialysis. his white blood cell count was noted elevated on admission and continued to increase but this was felt to be too large for a steroid dose. at the outside hospital, he was afebrile with negative blood cultures and skin cultures. skin biopsies were performed which did not support the diagnosis of vasculitis per report, although no specific details of the biopsy were available. ultrasound showed no deep vein thromboses, no specific arterial stenosis. based on the patient's status not improving, he was transferred to the for further evaluation. on admission, he noted that he had had no ulcers until ten days prior to admission here; at that time, he had the onset of small black ulcers and increased pain. he had no other complaints at that time. he had no fevers, chills, nausea, headache, neck pain, shortness of breath, or cough. he does have two-pillow orthopnea but he had no abdominal pain. he was admitted to the for further management. past medical history: 1. diabetes mellitus diet controlled. 2. chronic atrial fibrillation on coumadin. 3. morbid obesity. 4. restrictive lung disease. 5. gastroesophageal reflux disease. 6. renal insufficiency with a baseline creatinine of 3.0 to 3.5. 7. hypothyroidism. 8. obstructive sleep apnea. 9. history of ventricular tachycardia status post pacer and defibrillator. 10. gout on celebrex and prednisone for the past six months prior to admission. the prednisone dose was 10 mg a day. 11. history of lower extremity skin lesions. 12. history of pancreatitis. 13. status post cholecystectomy. 14. history of right rotator cuff tear. 15. umbilical hernia repair. 16. history of methicillin resistant staphylococcus aureus and vre. medications as an outpatient: 1. coumadin 2.5 and 5 mg alternating. 2. levoxyl 100 micrograms q. day. 3. betapace 120 mg twice a day. 4. prednisone 5 to 10 alternating. 5. zaroxolyn 2.5 q. day. 6. spironolactone 25 q. day. medications on transfer: 1. nexium 40 q. day. 2. prednisone 10 q. day. 3. betapace 120 q. a.m., 80 q. p.m. 4. nystatin powder to groin. 5. tums 500 three times a day. 6. bumex 2 mg q. day. 7. glipizide 10 mg q. day. 8. lactulose p.r.n. 9. levaquin 500 mg q. day. 10. vancomycin 1 gram q. day. 11. regular insulin sliding scale. allergies: penicillin and allopurinol, both of which gave him a rash. family history: father died at 54 of an myocardial infarction and also had hodgkin's disease. mother died at 81 of a myocardial infarction. social history: he lives with his wife in , . he is a retired corporate manager. he denies any history of tobacco; does not currently drink. no history of intravenous drug abuse; no history of blood transfusions. no other sexual partners. physical examination: on admission, in general, he was an obese man resting comfortably. the patient was afebrile; blood pressure 140/90; pulse 72; breathing at 22; saturation 99% on room air. heent examination was unremarkable. neck was supple; no jugular venous distention, no lymphadenopathy. lungs are clear to auscultation except for some decreased breath sounds at the right base. cardiovascular examination had distant heart sounds; regular rate and rhythm, a ii/vi systolic ejection murmur at the left sternal border radiating into the axilla. abdomen was obese, soft, nontender, nondistended, normal bowel sounds. no hepatosplenomegaly. positive incisional hernia. extremities revealed one to two plus edema to ankles bilaterally, two plus pulses symmetrical. skin: severe large up to 10 by 10 centimeter necrotic superficial ulcerations on lower extremities, more on the left than the right, with surrounding erythema. multiple areas of top layers with epidermis denuded. multiple small whitish lesions on buttocks approximately 3 to 4 centimeters in size. neurological examination was within normal limits. laboratory: on admission included a white blood cell count of 23.8, a hematocrit of 34.5, platelets of 171. inr on admission was 1.6 with a pt of 15, a ptt of 29. chem-7 revealed a glucose of 91, a bun of 171, creatinine 3.1. sodium 141, potassium of 3.9, chloride of 99, bicarbonate of 30, anion gap of 16. hospital course: the patient was admitted to the medicine firm where he would thus begin what would be a long hospital course: initially admitted to the medicine transferred to vascular for surgery and then transferred back to medicine for medical management prior to discharge. 1. lower extremity ulcers: the patient had lower extremity ulcers of which the exact etiology was never determined, but the most likely cause was ultimately ischemic vasculitis. the patient had a biopsy which showed evidence of changes from ischemic vasculitis, but possibly a component of calciphylaxis. he did have a significantly elevated calcium phosphate product on admission. the dermatology team was involved and they thought that possibly he had predisposing ischemic leg ulcers and some calciphylaxis which "tipped him over". this was never completely resolved. the patient went to the operating room on , for radical debridement of the left leg and debridement of the right leg. he then went back again on the 25th for a left above the knee amputation due to the severe nature of the ischemia and the ulcers that were being caused. he then went back on , for a debridement of the left above the knee amputation. he then went back on , for a skin graft from his abdomen to his right leg. the patient then stayed on the floor for healing and dressing care. at the time of discharge, his left above the knee amputation was still open so that it could debride and the plan was for him to be discharged and follow-up with dr. , his surgeon, in approximately two weeks. most likely the wound would be allowed to simply heal by secondary intention but if necessary, it would be closed. dr. would determine this later. at discharge, the wounds looked good, had no signs of infection present and the vascular team thought that the patient was safe for discharge from this perspective. 2. cardiovascular: the patient's postoperative and inpatient course was complicated by runs of monomorphic ventricular tachycardia in which his icd pacer fired. he was evaluated by the electrophysiology service for this and his betapace was stopped due to his renal failure, but he was started on amiodarone. he was ultimately taken to the electrophysiology laboratory where he was induced and a ventricular tachycardia ablation was performed. he was sent back to the floor and remained on amiodarone. approximately ten days before discharge, it was deemed that because of his ophthalmologic problems (see details below), that amiodarone was a possible cause since one of its side effects is optic neuritis. the patient also reported that amiodarone in the past had caused optic neuritis. when these were put together, it was decided that we should stop the amiodarone. ep was consulted and they agreed with this. his amiodarone was stopped. during the remainder of his hospital course, he remained paced; had one or two runs of four or five-beat monomorphic non-sustained ventricular tachycardia. ep service was aware of this but did not think that it was a problem. the ep service did state that they would like to change his pacemaker but that this was not an urgent issue. they recommended that he should be discharged to rehabilitation and then approximately a month or two later he could come back and seek cardiology care and he could go for an ep procedure and have his pacemaker changed. at the time of discharge, he had been hemodynamically stable for many days. 3. acute renal failure: the patient came in with a creatinine of 3.1 which went to 3.6 the next day. we believe that this was his baseline. his renal function remained at this level for roughly the first half of his stay. his creatinines then began to rise in the early part of . on , it went up to 4.0 and ultimately got as high as 6.4 on . the patient additionally began to be unable to tolerate p.o. he had significant nausea and vomiting. he had a flap on physical examination. we deemed that he had symptomatic uremia and the renal team decided to dialyze him. he was taken to dialysis approximately three or four times. this seemed to completely relieve his symptoms of nausea and vomiting and his flap resolved. after these few sessions of dialysis, his creatinine returned down to 3.3. the cause of his renal failure was believed to be atn, possibly due to hypotension at some point during his stay, since muddy brown casts were seen on a urine sediment examination. at the time of discharge, he had not had a dialysis for four days and his creatinine had remained in the mid-3 range. at the time of this dictation, the renal team did not think he would need any further dialysis and plans were being put into place to remove his dialysis catheter. an additional renal issue was that the patient had an incredibly high phosphors during his stay, with the level getting as high as 7.6 on . he had initially been treated with remegel to avoid constipation, but once his calcium phosphate product got so high and calciphylaxis was considered in the differential, it was decided to put him on amphojel. this subsequently brought his phosphate down very quickly. at the time of discharge, his phosphate was 3.0 and had remained within the normal range for four days prior. 4. hematology: at the time of admission, the patient's hematocrit was 32.1. it remained relatively stable in this range until the early part of . on , he had a hematocrit drop down to 23. he was given six units of blood and his repeat hematocrit was unchanged. it was feared that the patient had a significant bleed and he was transferred to the unit for this. ct scan of the abdomen was performed which was negative. the patient was guaiac negative, and after additional units of blood his hematocrit again returned up to the 30 range and he was transferred back to the floor. this happened a second time on , where his hematocrit dropped to 24.3. it did not bump with units of blood. this time, we did not transfer him to the medical intensive care unit but we continued to give him blood and his hematocrit finally came up. iron studies were done and he was slightly iron deficient so he was given iron supplementation. additionally, he was given epogen. we suspected that the patient may have some bleeding that we had not detected due to having uremic platelets. once he was dialyzed and his renal function improved, this hematocrit dropping phenomena ceased to be a problem. at the day of discharge, his hematocrit was 33.4 and it had been in the mid-30s for the four days prior to that. hemolysis labs were unrevealing as well during this work-up. 5. ophthalmology: several weeks prior to discharge, the patient began to note the onset of right eye blurriness. this became progressively worse to the point where he could barely see out of his right eye. ophthalmology consultation was obtained. they recommended checking a sedimentation rate which was high at 127 but the patient had known infection of his stump at this time and was on antibiotics, and it was deemed that this was not a reliable marker. the ophthalmology team was very concerned about the possibility of giant cell arteritis. the patient was put on 100 mg q. day of prednisone. a temporal artery biopsy was performed which was negative. we considered this to essentially rule out giant cell arteritis. an additional possibility was that it was amiodarone toxicity, although this would be unlikely to occur in only one eye; we stopped his amiodarone. at the time of discharge, his eyesight was still poor in that eye but had somewhat improved. the most likely diagnosis per the ophthalmology team was anterior ischemic optic neuropathy likely from atherosclerotic disease of the vessels in his eye. we suspect he may have had an episode of hypotension which is what made his vision so poor. it appeared that at the time of discharge, he was slowly recovering from this. the patient was recommended to have a full ophthalmologic work-up as an outpatient since there was nothing that could be done acutely for him in the hospital. his steroids were slowly tapered and at the time of discharge, he was back down to 10 mg a day which was the dose that he had come in on. 6. infectious disease: with the patient's elevated white count at presentation and his leg ulcers, there was significant concern for the patient to have infectious disease issues. multiple cultures of his blood and his wounds were done. a culture on the revealed only coagulase negative staphylococcus. tissue biopsy from one of his wounds revealed serratia and coagulase negative staphylococcus. the patient was started on broad-spectrum antibiotics. on , the patient had a catheter tip from one of his lines come back positive for enterococcus, resistant to vancomycin. the infectious disease team did not think treatment with liosol was indicated. the patient was continued on broad-spectrum antibiotics which consisted of flagyl, vancomycin and ceptaz. this was done in conjunction with frequent d??????bridements of his wounds that were done by the surgical team. at the time of discharge, he had had negative blood cultures for two weeks; he had been afebrile. his white count was elevated, but this was believed to be secondary to the large doses of steroids he was receiving for his ophthalmalgic issues. he was stopped on steroids two days prior to discharge. he remained afebrile. his white count remained elevated, but seemed to be slowly dropping and he was deemed safe to go home. 7. dermatology: the patient was noted to have a skin rash at one point during his stay and subsequently had a two-week course of acyclovir; the rash resolved and was not an issue at the time of discharge. 8. psychosocial: approaching the time of discharge, the patient began to get very agitated. he started to say he felt like he was trapped in his room and we thought this was a reasonable thing to say given how long he had been in the hospital. on the day prior to discharge, the physical therapy team was able to assist him in to a wheelchair and his wife was able to wheel him around the unit several times. this seemed to make him very tired, but he was pleased with this. he was very happy to hear the news about his discharge and i think he will do well on getting out of here. 8. pain: the patient had episodes of intense lower extremity pain especially in his right leg. it was not believed to be phantom pain since this was not the leg that had been amputated. ultrasounds were done which were unrevealing for deep vein thrombosis. the pain seemed to resolve on its own. however, during several points in his stay when he had received significant amounts of opioid analgesics, he did have some episodes of hallucination and confusion. we found these resolved when the patient was taken off of his opioids. because of this, we have advised him on discharge to avoid being treated with massive doses of opioids. he seems to do well with small amounts but too much seems to tip him over the edge. this is likely confounded by his problems with vision making it hard for him to make people out. condition on discharge: stable. discharge status: to rehabilitation facility. discharge diagnoses: 1. ischemic lower extremity ulcers status post left above the knee amputation, status post right skin graft. 2. acute renal failure secondary to acute tubular necrosis. 3. loss of vision in right eye likely due to anterior ischemic optic neuropathy. 4. anemia of unclear etiology. 5. monomorphic ventricular tachycardia status post ventricular tachycardia ablation. medications on discharge: 1. prednisone 10 mg q. day. 2. colace 100 mg p.o. twice a day. 3. protonix 40 mg q. day. 4. levoxyl 0.2 mg p.o. q. day. 5. neurontin 300 mg p.o. q. day. 6. niferex 150 mg p.o. q. day. 7. metamucil and lactulose as needed for bowel movements. discharge instructions: 1. follow-up will be with dr. for care of his lower extremity. 2. follow-up with cardiology to be arranged. 3. follow-up with nephrology to be arranged. 4. after this discharge, additionally, he will need to follow-up with his primary care physician. , m.d. dictated by: medquist36 procedure: hemodialysis venous catheterization for renal dialysis excision or destruction of other lesion or tissue of heart, endovascular approach other skin graft to other sites excisional debridement of wound, infection, or burn excisional debridement of wound, infection, or burn amputation above knee repair of entropion or ectropion with wedge resection revision of amputation stump biopsy of blood vessel diagnoses: acute kidney failure with lesion of tubular necrosis diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled paroxysmal ventricular tachycardia iron deficiency anemia, unspecified infection and inflammatory reaction due to other vascular device, implant, and graft atherosclerosis of native arteries of the extremities with gangrene hypercalcemia fitting and adjustment of automatic implantable cardiac defibrillator optic neuritis, unspecified 

Answer: The patient is high likely exposed to