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: no known allergies / adverse drug reactions attending: chief complaint: abnormal labs; weakness, altered mental status major surgical or invasive procedure: intubation central venous line placement arterial line placement trach/peg history of present illness: mr. is a 66 year old man with ckd (baseline cr 1.7-2), cad, chronic back pain and recent hospitalization after a fall with altered mental status and acute on chronic renal failure who presents from home with weakness. patient was discharged from rehab two weeks ago. was initially doing well at home, but started having difficulty getting up and being active for a week. per report, increased confusion, waxing and in nature, over the last couple of days. vna came to his home yesterday and drew labs which were notable for a elevated creatinine of 3.59 and hyperkalemia. he was brought to the ed for further evaluation and management. . in the ed, initial vs were: t 97.3 hr78 bp113/55 rr16 o2 sat95% ra. initial ed labs were otherwise notable for k of 7.4, creatinine of 6.4 and bun of 106. ekg with peaked t waves. patient received kayexelate, calcium gluconate, bicarb, 10 units of insulin and 1 amp d50 with minimal improvement of k to 4.9 (after an interval increase to 8.8). renal was consulted and recommended renal u/s, more d50 with bicarb, and placement of an hd line for emergent dialysis. three hours into his ed visit an ekg was done, which was remarkable for st elevations in the inferior leads, ii, iii, avf. initial cardiac markers were notable for troponin 3.70, ck 3965 and mb 82. repeat troponin 3 hours later was 4.03. he was given aspirin 81, but given guaic positive stool heparin and plavix was held. cardiology was notified and deferred catheterization secondary to time elapsed and his multiple other co-morbidities. other notable labs from the ed included an initial wbc was 15 with 93% neutrophils. ua was notably dirty with >50 wbcs and a lactate of 2.2. patient had a ph of 7.23 with an anion gap of 18. patient's blood pressures dropped to 80s/50s, he received 3 liters of fluid in boluses and he was started on dopamine and neo. pressures improved to 110s. patient's sat's started to drop and he was showing signs of increased wob. he was subsequently intubated with rocuronium and etomidate. lij hd catheter was placed. he was given a dose of vancomycin and ctx for presumed urosepsis. . vs prior to transfer were afebrile, hr129 bp113/74 o2 sat 100% on vent. in the micu, patient was intubated. patient underwent beside echo with akinesis of inferior wall, ef of about 40%. . review of systems: unable to obtain given to patient's altered mental status. past medical history: coronary artery disease macular degeneration chronic back/leg pain secondary to djd tremor peripheral neuropathy abdominal bruit chronic renal failure believed secondary to vascular disease (, cr: 2.6 and bun 49, k: 5.9) gerd anemia (: hct: 33.5) bilateral cea depression hyperlipidemia colonic polyps??? copd???, in record, however patient denies left and right total hip replacements pvd: mild-moderate aorto--ilac disease as noted in social history: denies current tobacco use (h/o 20+ pack year, quit 15-20 years ago) admits to approximately 2+ beers most nights of the week. denies h/o illicit drug use. lives with wife. family history: non-contributory physical exam: on admission: vitals: t 97.5 bp: 124/107 p: 118 r: 22 o2: 100% (on ac fio2 100%, peep 10, tv .500) general: alert, intubated; follows simple commands heent: endotracheal tube in place; mmm, r eye with ptosis; perrl neck: supple, no jvd, lij hd catheter in place lungs: clear to auscultation in r field anteriorly; coarse bs in left anterior lung field;, no wheezes, rales cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: cool to touch, diminished dp and pt pulses, intact radial pulses; non-blanching violaceous ischemic appearing macules on toes b/l; heel ulceration with deep necrosis r>l; no exudates or purulence visible; 1+ pedal edema back: unstageable sacral decubitus ulcer with necrotic appearance . on discharge: general appearance: awake, alert, following commands, nad heent: eomi, sclera anicteric, mucus membranes moist neck: trach collar in place, site clean and dry cardiovascular: regular but slightly tachycardic, no r/m/g appreciated respiratory / chest: coarse bs bilaterally with decreased bs at bases, no wheezes or rales abdomen: soft, nt/nd, bowel sounds present extremities: right foot cooler than the left, warmer on exam today compared to yesterday neurologic: alert, cns grossly intact, sensation intact, still somewhat delirious, oriented to person, year, season pertinent results: admission labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 15.0* 3.40* 10.6* 32.2* 95 31.3 33.0 13.9 352 glucose urean creat na k cl hco3 angap 131*1 106* 6.4* 7.4*11 99 13*12 30* . pertinent labs: 07:42 ck-mb mb indx ctropnt 157* 3.0 5.37*1 20:44 79* 2.3 4.95*1 caltibc vitb12 folate ferritn trf 233* 724 7.8 342 179* 15:45 fio2 o2 flow po2 pco2 ph caltco2 base xs aado2 req o2 intubat vent 12/ 409* 44 7.46* 32* 7 assist/con1 intubated . discharge labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 8.2 2.46* 8.0* 23.1* 94 32.6* 34.8 17.7* 62* glucose urean creat na k cl hco3 angap 143*1 56* 1.7* 145 4.0 105 28 16 alt ast alkphos totbili 44*2 229*3 65 0.2 ................................................................ micro: , , urine cx: enterococcus ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- <=1 s vancomycin------------ 2 s . blood cx: enterococcus ampicillin------------ =>32 r daptomycin------------ s linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r ................................................................ studies: ekg: sinus rhythm. inferior st elevation myocardial infarction. compared to the previous tracing of myocardial infarction pattern is new. . cxr: mild cardiomegaly, but no acute intrathoracic process. . tte (bedside): left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. lv systolic function appears depressed (ejection fraction 30%) secondary to severe hypokinesis/akinesis of the inferior and posterior walls. the right ventricular cavity is dilated with depressed free wall contractility. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is no pericardial effusion. impression: inferior posterior infarction; right ventricular infarction . ekg: sinus tachycardia. inferior st segment elevations with rare reciprocal precordial depressions are suggestive of inferoposterior myocardial infarction. compared to the previous tracing st-t wave changes are more extensive. . renal u/s: atrophy of the right kidney is unchanged. the left kidney is normal. no hydronephrosis or mass noted. . tte: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with inferior/inferolateral akinesis and hypokinesis of the inferior septum. doppler parameters are indeterminate for left ventricular diastolic function. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: inferior/inferolateral akinesis and septal hypokinesis consistent with inferior infarction/ischemia. dilated and hypokinetic right ventricle likely due to ischemia/infarction. . cxr: compared to most recent prior, there is increased pulmonary vascular prominence, consistent with vascular congestion. cardiomegaly is stable compared to prior. persistent retrocardiac density likely represents a combination of atelectasis and left pleural effusion. there is increased opacity at the right base, consistent with atelectasis. an endotracheal tube is seen with the tip approximately 6.5 cm above the carina. a left internal jugular line is seen with tip projecting over the mid svc. an intestinal tube is seen traversing the diaphragm with tip coiled in the stomach. impression: increased right basilar atelectasis with stable pulmonary edema. . ct abd/pelvis: 1. atrophic right kidney with extensive vascular calcifications. no renal calculi identified. 2. bilateral small pleural effusions and atelectasis. 3. gallbladder wall edema likely due to third spacing and possible hepatitis; this is unlikely to be cholecystitis, but correlation with physical exam is recommended. . ruq u/s: 1. no son signs of cholecystitis. no gallstones and no sludge identified. 2. atrophic right kidney again noted. 3. mild splenomegally. . rue u/s: 1. occlusive clot in the right cephalic vein. of note, the cephalic vein is a superficial vein. 2. otherwise, no deep vein thrombosis in the right upper extremity. . cxr: et tube is in standard placement. left internal jugular line ends at the origin of the left brachiocephalic vein. nasogastric tube passes below the diaphragm and out of view. mild pulmonary edema has not changed appreciably since . heart size is normal. small left pleural effusion is likely. lateral aspect left lower chest is excluded from the examination. there is no evidence of pneumothorax along the imaged pleural surfaces. . cxr: left ij catheter tip is in the proximal svc. there is no pneumothorax. cardiac size is top normal. et tube is in standard position. ng tube tip is in the stomach. if any, there is a small right pleural effusion. bibasilar opacities are improved, consistent with improving atelectasis. persistent opacities in the right perihilar region, and right lower lobe that have improved from , stable from earlier in the morning, are a combination of atelectasis and pleural effusion. superimposed infection cannot be totally excluded. . cxr: ap chest compared to through 4: over the past 24 hours, pulmonary edema has worsened, moderate cardiomegaly and mediastinal vascular engorgement have increased and small bilateral pleural effusion, left greater than right, has increased as well. findings are more consistent with cardiogenic edema than non-cardiogenic. left internal jugular line ends in the svc. . ct chest: 1. moderate bilateral pleural effusions, right greater than left, without evidence of loculation. bilateral adjacent dependent atelectasis, with slightly heterogeneous in shape on the right. possible right lower lobe pneumonia. no cavitary lesion. 2. severe centrilobular emphysema. 3. two sub-5-mm perifissural nodules. given the underlying emphysema and increased risk for lung cancer, recommend followup in 6 to 12 months for stability. 5. moderate-to-severe 3-vessel coronary artery disease. moderate systemic atherosclerotic disease. 6. ett tip 7cm above carina, and nasogastric tube ends in the proximal stomach with most proximal sideport in the distal esophagus. consider advancing both for better positioning. . cxr: as compared to the previous radiograph, there is no relevant change. widespread parenchymal opacities are constant. enlarged pulmonary vessels suggest that these opacities are predominantly caused by edema. in addition, particularly at the right lung bases, a second opacity is seen that shows subtle air bronchograms and could reflect pneumonia. moderate retrocardiac atelectasis. the presence of small pleural effusions cannot be excluded. . 3/12/1 kub: portable ap radiograph of the abdomen was reviewed with no relevant prior studies available for comparison. the limited view obtained in portable technique of supine ap abdomen demonstrates known percutaneous gastrostomy. there is diffuse pattern of bowel gas that might be consistent with ileus, although the pattern is nonspecific and no dilatation of the bowel is present. there is left lower lobe atelectasis and small amount of pleural effusion seen. . ct head: no evidence of an acute intracranial process. . ct torso: 1. moderate-sized bilateral pleural effusions, with associated opactities of both lower lobes. superimposed infection cannot be excluded, but the appearance could be explained by atelectasis. effusions are similar, but parenchymal opacity has improved somewhat at the right lung base. 2. no evidence of bowel obstruction or ileus. 3. tracheostomy tube, left upper extremity picc, and a percutaneous gstrostomy tube are in optimal position. 4. extensive atherosclerotic calcification of the aorta and the coronary arteries. . cxr: as compared to the previous radiograph, there is no relevant change. the tracheostomy tube is in unchanged position. unchanged mild bilateral pleural effusions. unchanged evidence of mild pulmonary edema. retrocardiac atelectasis. normal size of the cardiac silhouette. no newly occurred focal parenchymal opacities. brief hospital course: 66 year old man with ckd (baseline cr 1.7-2.3), cad, chronic back pain and recent hospitalization for altered mental status and acute on chronic renal failure, who presents from home with weakness and altered mental status in the setting of stemi and shock. . # goals of care: patient has a progressive deterioration over the course of his hospital stay, with many complications. on patient developed recurrent episodes of vt (see below), and family decided to make patient dnr/i with goals of care being lack of escalation, but with plan to continue current therapeutic measures. . # shock/urosepsis: patient was admitted to the micu on dopamine and neo for blood pressure support. an arterial line was placed for hemodynamic monitoring. he was transitioned to levophed and vasopressin and was gradually weaned off of pressors as his blood pressures improved. patient's shock was attributed to sepsis rather than a cardiogenic presentation given his high mixed venous oxygen saturation and hyperdynamic cardiac function. the source of his sepsis was attributed to a uti given his dirty ua and eventual multiple enteroccocal urine cultures. he was treated empirically with vancomycin and cefepime, and cipro was added when fevers persisted. blood cultures were initially negative, but eventually grew enterococcus (vre). antibiotics were switched to daptomycin and patient's lines were removed and replaced. patient was transitioned to linezolid and meropenem, and subsequent cultures were negative. . # respiratory failure: patient was intubated increased work of breathing and was put on assist control ventilation. initial cxr was without focal consolidation, but with signs of pulmonary congestion after resuscitation with 3 l ivf. attempted to wean patient off vent but ran into difficulty as diuresis was limited by patient's compromised cardiac function and pre-load dependence after his inferior mi. in addition, patient developed a mrsa pneumonia for which he was treated with 8 days of vancomycin. patient was extubated on , but reintubated on for increased work of breathing. on trach and peg were placed at bedside. patient intermittently required lasix and he has responded to lasix 80 mg iv. we would advise using lasix intermittently to maintain euvolemia. . # stemi: patient suffered an ste inferior mi with depressed rv function (dilated and hypokinetic on serial echos). cardiology was consulted in the ed and patient was medically managed with heparin, plavix, asa, statin. cardiac catheterization was not pursued as it was felt there was little therapeutic benefit to intervention. the heparin drip was stopped after 48 hours. attention was paid to his blood pressure given his preload dependence and small boluses of ivf were given as needed. eventually his blood pressures stabilized and it was possible to gently diurese with lasix drip to attempt to wean patient off vent. patient was tachycardic and was started on metoprolol which was gradually uptitrated. . # acute on chronic renal insufficiency: patient with baseline creatinine of 2.3, presenting here with initial creatinine of 6.4 and hyperkalemia to 7.4. acute renal failure was attributed primarily to obstruction as urine output picked up quickly and creatinine trended down rapidly after foley was placed. however, renal u/s did not show signs of hydronephrosis. atn was felt less likely given the speed of recovery and the relatively acute onset of hypotension in the ed which was quickly addressed with pressors. regardless of etiology, patient's renal function rapidly improved and his creatinine trended down as low as 1.0. his new baseline appears to be 1.2 to 1.8. . # ventricular tachycardia: on patient developed in the setting of desaturating from presumed mucous plugging. patient had 6 episodes, 2 that self terminated, and 4 that required synchronized shock because of loss of pulse. patient was bolused with iv amiodarone and then transitioned to oral amiodarone. his betablocker was stopped. plan to continue amiodarone 400 mg tid for 1 week, then switch to 400 mg for 2 weeks, and then transition to amiodarone 400 mg daily therafter. . # thrombocytopenia: patient developed thromobcytopenia to the 70s, and heparin was discontinued. hit antibody was pending at the time of discharge, and as such we have held heparin products. platelet count nadir was in the 50s, and improved to 62 on the day of discharge. we would ask that his facility please call in order to check on the status of his antibody on . we will also try to reach out to the facility in order to facilitate this process. for now, please hold heparin products. . # guaiac positive stool/anemia: patient with guaiac positive stool in ed. has known severe (grade 3) erosive esophagitis and gastritis on egd in . hct similar to prior hospitalization, baseline may be in mid 30s. he was continued on his home ppi and did drop his hct slightly while on the heparin drip. he was transfused 2 units on and , and one unit on , and . . # wounds: patient with deep necrotic heel ulcers and advanced sacral decubitus ulcer. per wife these are relatively new and likely developed during stay in rehab. wound care was consulted and provided recommendations for dressing changes. patient was seen by vascular surgery when there was concern that the heel ulcers may have been infected and contributing to his fevers, however it was felt the ulcers were not infected and no further intervention was pursued. general surgery was consulted regarding the sacral decub and perforemed bedside debridement on . wound care consult on made the following recs # discontinue dakins to bilateral feet cleanse all wounds with wound cleanser then pat dry # aloe vesta to b/l le's and feet # for left foot ulcers: xeroform dressing daily - cover with dry gauze/abd and secure with kerlix change daily # for right foot: duoderm gel to ulcers ( none on achilles ulcer) then cover with moist ns gauze cover with dry abd then wrap with kerlix change daily # for sacrum : no sting barrier to periwound tissue then antifungal powder continue with santyl - rub into /yellow tissue cover wound with moist ns gauze cover with abd or softsorb dressing secure with pink hy tape to protect from stooling change daily . # depression: on clonazepam and olanzapine at home, which were held given acute illness and restarted prior to discharge. medications on admission: clonazepam 2mg qam olanzapine 20 qam metoprolol tartrate 50mg diltiazem 300mg sr qd asa 81mg qd gabapentin 100mg tid protonix 40mg colace ferrous sulfate carafate slurry qid senna tylenol prn dilaudid 2 mg po prn dressing changes discharge medications: 1. atorvastatin 80 mg tablet : one (1) tablet po daily (daily). 2. polyethylene glycol 3350 17 gram/dose powder : one (1) pack po daily (daily) as needed for constipation. 3. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 4. sodium hypochlorite 0.5 % solution : one (1) appl miscellaneous asdir (as directed). 5. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day) as needed for constipation. 6. insulin lispro 100 unit/ml solution : one (1) unit subcutaneous asdir (as directed): per sliding scale. 7. ascorbic acid 500 mg tablet : one (1) tablet po daily (daily). 8. collagenase clostridium hist. 250 unit/g ointment : one (1) appl topical daily (daily). 9. aspirin 325 mg tablet : one (1) tablet po daily (daily). 10. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 11. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 13. quetiapine 25 mg tablet : 0.5 tablet po hs (at bedtime) as needed for anixety or insomnia. 14. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : six (6) puff inhalation q6h (every 6 hours) as needed for wheezing. 15. amiodarone 200 mg tablet : two (2) tablet po tid (3 times a day): for 1 more week, then 400 mg for 2 weeks, then 400 mg daily. 16. clonazepam 1 mg tablet : one (1) tablet po bid (2 times a day). 17. acetaminophen 650 mg/20.3 ml solution : six y (650) mg po q6h (every 6 hours) as needed for fever, pain. 18. fentanyl citrate 25-100 mcg iv q2h:prn pain 19. midazolam 0.5-2 mg iv q2h:prn anxiety discharge disposition: extended care facility: - discharge diagnosis: septic shock stemi ventricular tachycardia urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: you presented to the hospital with weakness and confusion. you were found to have a severe heart attack and a blood infection. you developed problems with your lungs related to fluid overload and pneumonia. you were extubated, but need to have a breath tube placed again. you also had several irregular heart rhythms that required electric shocks. eventually a tracheostomy and peg feeding tube were placed. given your overall medical condition, the decision was made to make your goals of care do not resuscitate. you are being discharged to a rehab facility in order to continue your care. followup instructions: please follow up with your primary care doctor as you see necessary md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus nonexcisional debridement of wound, infection or burn nonexcisional debridement of wound, infection or burn injection or infusion of oxazolidinone class of antibiotics diagnoses: acidosis hyperpotassemia thrombocytopenia, unspecified coronary atherosclerosis of native coronary artery pure hypercholesterolemia urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) severe sepsis chronic airway obstruction, not elsewhere classified atherosclerosis of aorta hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified chronic kidney disease, unspecified pulmonary collapse paroxysmal ventricular tachycardia dysthymic disorder acute respiratory failure cardiogenic shock septic shock infection with microorganisms without mention of resistance to multiple drugs acute myocardial infarction of other inferior wall, initial episode of care paralytic ileus pressure ulcer, lower back do not resuscitate status pressure ulcer, heel hyperosmolality and/or hypernatremia other and unspecified infection due to central venous catheter ventilator associated pneumonia streptococcal septicemia delirium due to conditions classified elsewhere rhabdomyolysis other esophagitis acute on chronic combined systolic and diastolic heart failure diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled methicillin resistant pneumonia due to staphylococcus aureus atherosclerosis of other specified arteries pressure ulcer, unstageable atrophic gastritis, with hemorrhage 

Answer: The patient is high likely exposed to