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 58-year-old gentleman with a complicated medical history including type 1 diabetes mellitus (poorly controlled with triopathy), coronary artery disease, congestive heart failure, hypertension, peripheral vascular disease who was recently admitted to where he was intubated for congestive heart failure and transferred to with a non-st-elevation myocardial infarction. the patient was in respiratory distress and also required emergent dialysis (acute renal failure for initiation of hemodialysis for volume overload) and anemia (requiring recent transfusions) and discharged home on without outpatient nephropathy and cardiology appointments. the patient presents with one and a half weeks of left lower extremity pain, redness, and rash bilaterally. he reports being seen by dermatology without treatment. he was given prednisone for possible gout as well as vicodin by his primary care physician. has had increased pain and can hardly walk. no fevers, chills, chest pain, shortness of breath, or back pain. the pain is the worst the patient has ever experienced in his life, even to light touch. he has increased swelling of the left foot and no trauma. in the emergency department, blood cultures were drawn. morphine sulfate 2 mg times four was given. oxacillin 2 grams times one was given. the patient's pain went from to . he also received intravenous fluids. past medical history: 1. type 1 diabetes mellitus (with recent diabetic ketoacidosis). 2. coronary artery disease. (a) status post coronary artery bypass graft in . (b) status post a non-st-elevation myocardial infarction on . (c) a stress on showed no perfusion defects and an ejection fraction of 40%. moderate new fixed defect. 3. neuropathy. 4. retinopathy. 5. chronic renal insufficiency (with recent acute renal failure; started hemodialysis on to ). a renal ultrasound in was consistent with chronic interstitial disease. 6. status post carotid endarterectomy in . 7. peripheral vascular disease; status post revascularization on the left times two and on the right times three. 8. hyperlipidemia. 9. history of glaucoma. 10. gastroesophageal reflux disease. 11. anemia; status post transfusions in . 12. congestive heart failure (with an ejection fraction of 51% on echocardiogram in and 40% on persantine mibi in ). also with symmetric left ventricular hypertrophy, 1 to 2+ mitral regurgitation, as well as anteroseptal and apical hypokinesis. 13. hypertension. 14. magnetic resonance angiography of the kidneys in with mild stenosis of the proximal renal artery on the right. 15. no history of gout or cellulitis. allergies: no known drug allergies. medications on admission: 1. aspirin 325 mg by mouth once per day. 2. lipitor 10 mg by mouth once per day. 3. hydralazine 100 mg q.6h. 4. imdur 30 mg by mouth three times per day. 5. atenolol 75 mg by mouth once per day. 6. glargine insulin 8 units subcutaneously at hour of sleep. 7. humalog sliding-scale. 8. calcium carbonate. 9. prednisone 20 mg by mouth once per day (recently decreased); this was started two weeks ago for gout. 10. vicodin as needed. 11. lasix 40 mg by mouth twice per day (recently restarted). social history: the patient is married. the patient has a 23-pack-year history of tobacco; quit 10 years ago. social alcohol use. family history: family history of coronary artery disease in a brother. brother with a myocardial infarction at the age of 40. no diabetes. physical examination on presentation: physical examination revealed the patient's temperature was 97.3 degrees fahrenheit, his heart rate was 58, his blood pressure was initially 230/83 (going down to 177 systolic), his respiratory rate was 18, and his oxygen saturation was 94% on room air. in general, the patient was a gentleman in no acute distress. the patient was diaphoretic. head, eyes, ears, nose, and throat examination revealed the mucous membranes were dry. the lungs were clear to auscultation with right basilar crackles; otherwise, clear. cardiovascular examination revealed a regular rate and rhythm with a systolic murmur. the abdomen was soft and nontender. back examination revealed no tenderness. extremity examination revealed the left foot with dorsal edema (pitting), erythema on the left lateral around the medial malleolus, some left lateral leg erythema. there were dopplerable pulses. motor strength was in the left ankle but with pain bilaterally. the right foot with edema but less than on the left. extensor hallucis longus weak bilaterally. pertinent laboratory values on presentation: laboratories revealed the patient's white blood cell count was 16.2, his hematocrit was 32.9, with a mean cell volume of 94, and his platelets were 273. differential with 94% neutrophils, 0% bands, 2.6% lymphocytes, 3.1% monocytes, 0.3% eosinophils, and 0.1% basophils. the patient's sodium was 134, potassium was 4.9, chloride was 101, bicarbonate was 24, blood urea nitrogen was 130, creatinine was 3.3, and blood glucose was 260. pertinent radiology/imaging: a left ankle film revealed cortical irregularities along the medial malleolus and small osseous fragment distal to the tip of the medial malleolus and lateral to the medial malleolus. the medial malleolus fragment was linear and appeared less likely to be chronic in nature. there was no dislocation or destructive osseous lesions. there was soft tissue swelling noted around the medial and lateral malleoli. there was no evidence of osteomyelitis, small fragments around the medial and lateral malleoli were more consistent with an acute fracture, although they both may be chronic. a chest x-ray revealed mild-to-moderate congestive heart failure and cardiomegaly. concise summary of hospital course by issue/system: the patient was admitted to the medicine service. the following is a summary of the hospital course by issue/system. of note, this is a discharge summary through the date of . a discharge summary addendum will be added from until the day of discharge summarizing the remainder of the hospital course, medication, and followup. 1. foot issues: the patient was started on oxacillin for treatment of his cellulitis. repeat ankle films were done on , as the patient remained with an elevated white blood cell count. this revealed old inferior malleolar medial evulsion injuries. possible small evulsion injury at the anterolateral aspect of the tibia is unusual location in the absence of point tenderness and likely little clinical significance. the patient remained afebrile throughout his hospitalization, but given his foot infection on , ciprofloxacin was added given his diabetes and prednisone was held. the patient was kept with leg elevation, nonweightbearing, and multipoultice boot. on , the patient's white blood cell count was noted to rise slightly. therefore, oxacillin was discontinued and vancomycin was started given the recent hospitalizations and therefore at increased risk of having a resistant bug. additionally, rheumatology was consulted who felt that gout was not suspected in this case and there was no evidence for septic arthritis. therefore, they did not recommend an arthrocentesis but did recommend a magnetic resonance imaging of the leg. additionally, the vascular service was consulted and continued to follow the patient throughout the hospital course. they recommended arterial duplex of the lower extremities given the patient's history of bypass graft bilaterally. this showed widely patent left-sided femoral-tibial bypass graft; however, it did show high-grade stenosis within the medial portion of the patient's jump graft on the right at approximately the gastrocnemius level. given that the left graft was patent and it was the left side with the cellulitis, it was felt no intervention was need at this time. however, flagyl was added for further coverage. the erythema of the area did improve slightly, but there was a darkened area that appeared more ecchymotic than necrotic which remained unchanged. the patient remained requiring narcotics for pain control. on the following day, a magnetic resonance imaging of the left lower extremity was done. this showed no evidence of acute fracture. it showed peroneal tenosynovitis with surrounding soft tissue edema and adjacent bone marrow edema involving the posterolateral lateral malleolus and lateral aspect of the calcaneous and diffuse soft tissue and subcutaneous edema most marked in the plantar deep tissues. no discrete deep fluid collection and minimal enterosepsis tear of the distal achilles tendon. the patient was maintained on these antibiotics dosing vancomycin by levels and given 1 g intravenous times one every day if level was less than 15. his ciprofloxacin was renally dosed as was his flagyl. the patient remained afebrile, but the white blood cell count did not really trend down. it remained approximately in the range of 14 to 17. on , the vascular service debrided the eschar at the bedside and purulent serous fluid drained and was sent for culture. the podiatry service was consulted who recommended a repeat magnetic resonance imaging to assess the left foot for the possible need of operating room debridement. this showed diffuse muscle and subcutaneous edema with fluid extending to the sagittal planes in the left greater than right calf edema nonspecific with the differential including infectious myositis or diabetic myonecrosis. diffuse subcutaneous and fascial edema may be related to cellulitis fluid overload, venous insufficiency, or fasciitis. no focal abscess was identified. on , it was decided that because of the possible spread and seeding of further tissues the patient needed to go to the operating room for incision and drainage and exploration. the patient had an incision and drainage of the left ankle under local anesthesia and mac anesthesia. during this procedure 10 cc to 15 cc of purulent discharge was found and cultured as well as liquefying necrosis being found. the day after the debridement, the patient's white blood cell count was noted to rise acutely to 18 but trended down after that after day. on , the white blood cell count was 9.9. on , the white blood cell count was 12.1. dressing changes were done twice per day (per podiatry recommendations), and the patient remained nonweightbearing with foot elevation and multipoultice boot in place. the patient's pain was well controlled using tylenol 1 gram q.6h., oxycodone as needed, and intravenous morphine only for breakthrough pain. blood cultures from remained negative. a urine culture from remained negative. swabs from the bedside incision and drainage on showed 1+ polymorphonuclear leukocytes on gram stain but grew nothing on culture. swabs from the operating room on grew rare staphylococcus coagulation positive. on , this was found to be sensitive to oxacillin. therefore, the patient was changed from vancomycin to oxacillin. blood cultures from were negative to date. at this time, in discussion with the vascular service and podiatry service, we will repeat noninvasive studies of the left leg to assess left leg blood flow all the way distally, and the patient may need further operating room debridement depending on how the wound does. 2. congestive heart failure issues: on , the patient had a chest x-ray showing moderate congestive heart failure with desaturations to 87% on room air. the patient received lasix 20 intravenously, and his oxygen saturations improved. the patient did not have symptoms of shortness of breath. his standing lasix had been discontinued secondary to increased creatinine, and lasix was then dosed as needed secondary to his creatinine and clinical fluid status. on , the patient was again noted to desaturate to 88% on room air. he was also noted to have an elevated jugular venous pulsation. a repeat chest x-ray showed cardiomegaly with pulmonary vascular engorgement with interstitial edema with small bilateral pleural effusions; essentially unchanged from . at that time, secondary to his acute-on-chronic renal failure, it was felt prudent to start natrecor rather than use lasix to attempt diuresis. the patient was started 0.01 mcg/kg per minute. the patient continued to have intermittent oxygen needs and jugular venous pulsation as well as crackles in his lungs. on , he was noted to have an improving lung examination and a decreasing need. he was on room air. however, a chest x-ray on showed persistent vascular engorgement, bilateral perihilar haziness, as well as diffuse interstitial pattern; probably unchanged, but a right small pleural effusion did slightly increase. therefore, lasix was added to the natrecor starting at his outpatient dose. over the course of the next several days, the patient was noted to have worsening oxygen saturations and an increasing oxygen requirement as well as a worsening lung examination with increasing rales; however, the patient remained asymptomatic throughout this. his lasix was titrated up as was his natrecor which was increased to 0.015 mcg/kg per minute. on , the patient had a repeat chest x-ray which showed worsening congestive heart failure. however, despite this, it was felt urgent and necessary to take the patient to the operating room on for debridement of his infection to help prevent spread and further seeding. after the procedure, the patient was noted to have significantly increasing oxygen requirements to maintain oxygen saturations above 90% as well as dyspnea. the patient received a total of lasix 200 intravenously in the postanesthesia care unit and was able to be weaned to nasal cannula oxygen and return to the floor. on , the congestive heart failure service was consulted given the patient's difficult fluid management. they recommended increasing the natrecor to 0.02 mcg/kg per minute. additionally, the recommended fluid restriction as had been done and to continue the lasix at 80 intravenously twice per day. for the subsequent days, the patient diuresed about negative one liter per day and his weight trended down. when the patient is dry will have to tell him dry weight so that he can follow this closely as an outpatient. at this time, the patient's oxygen need was decreasing and his lung examination was significantly improved. a chest x-ray from showed a slight improvement in congestive heart failure and continued bilateral right greater than left pleural effusions. the patient was to be set up with an appointment in the heart failure clinic to follow up upon discharge. 3. renal issues: on admission, the patient was noted to have a creatinine of 3.3 and a blood urea nitrogen of 130. this was significantly higher than his known baselines which were a creatinine of 2 to 3 and a blood urea nitrogen of 50 to 80. on , his creatinine was noted to rise to 3.8. fractional excretion of sodium was calculated at 0.8, but the patient had been on lasix as an outpatient. a urine culture was negative, and urine eosinophils were negative. the patient did receive some lasix given his congestive heart failure. on , the patient's creatinine was noted to rise again. the renal service was consulted who suggested holding the lasix; which is why natrecor was started, to help with diuresis. the patient's creatinine during this hospitalization was 4.4 and after that his creatinine was noted to trend down and stabilize between 2.5 and 3.1. previously, the patient had been noted to have mild renal artery stenosis on the right. a renal ultrasound was repeated on which showed no significant change compared to . there was no evidence of hydronephrosis, stones, or masses. the right kidney was 13.3 cm and the left kidney was 11.4 cm. there was increased echogenicity in both kidneys. dialysis was considered to help with the heart failure; however, given that the patient was having good urine output to natrecor and lasix, it was decided to hold off on the initiation of dialysis. however, it was discussed with the family and the patient that he may require dialysis in the upcoming months. additionally, the transplant team (dr ) was consulted to start discussing access for dialysis with the patient, and venous mapping was done. all medications were renally dosed, and nephrotoxic medications were avoided as much as possible. 4. hematologic issues: on admission, the patient's hematocrit was 32.9. it appeared from previous records that his baseline hematocrit was in the low 30s. the patient had been epogen on admission; however, the patient's hematocrit was noted to fall slightly. he was found to be guaiac negative. hemolysis laboratories were sent and were negative. however, iron studies showed an iron of 14 with a total iron-binding capacity of 233. therefore, given the significant iron deficiency, epogen was stopped and the patient was given five days of intravenous iron gluconate and changed to by mouth iron. he also received transfusions to keep his hematocrit above 28.9. the patient's hematocrit was noted to fall as low as 25 and 26 on several occasions. it was felt that this was more likely due to blood loss from phlebotomy and procedures such as incision and drainage, open wound, and peripherally inserted central catheter line in the setting of anemia of chronic disease. the patient was transfused for this. epogen 4000 units subcutaneously twice per week was restarted. at the time of this dictation, the patient had received a total of 6 units of packed red blood cells during his hospital course. the patient will likely need an outpatient esophagogastroduodenoscopy and colonoscopy for surveillance if this has not been done. 5. diabetes issues: the patient was maintained on a diabetic diet, and glargine at hour of sleep as he was on as an outpatient, and a humalog insulin sliding-scale. on , the patient was noted to have an anion gap of 17. he had trace ketones in his urine, but large acetones in his blood. arterial blood gas showed a ph of 7.41, a pco2 of 35, and a pao2 of 59, and lactate was 1.7. it was felt the patient was in diabetic ketoacidosis, although the etiology was unclear. it was possible that this was due to stress from the operating room or possibly a missed insulin dose. the patient was ruled out by enzymes for a myocardial infarction. however, the patient was given 6 units of nph and was followed closely q.4h. with a humalog insulin sliding-scale. a medical intensive care unit consultation was called for the possible need of intravenous insulin; however, the patient did not require medical intensive care unit care. he was followed closely with his glargine and humalog insulin sliding-scale. 6. hypertension issues: on admission, the patient was noted to be very hypertensive. it was thought that perhaps this was secondary to pain and missed medications prior to admission. however, it remained elevated. therefore, medications were titrated up. his atenolol was limited to 100 mg once per day by heart rate, and the hydralazine was maximized at 100 mg q.6h. the patient was continued on isordil. even with the initiation of natrecor, the patient's systolic blood pressures remained elevated. the atenolol was changed to labetalol 200 mg twice per day. the patient's systolic blood pressure remained high, so nifedipine-cr 30 mg once per day was added. after a discussion with the renal team, our systolic blood pressure was 140. the patient's blood pressures were checked lying and sitting and were the same. at the time of this dictation, the patient's blood pressures were under somewhat better control; although, they were somewhat labile. blood pressures will need to be followed closely as significantly elevated blood pressures most likely will make his congestive heart failure difficult to control. 7. coronary artery disease issues: on admission, the patient was ruled out for a myocardial infarction by cardiac enzymes. he had a troponin of 0.05, but this was felt to be secondary to his congestive heart failure and renal failure and not an acute myocardial infarction. the patient was monitored on telemetry and was only noted to have rare single premature ventricular contractions and occasional sinus bradycardia. the patient was nauseous intermittently, but the electrocardiograms remained unchanged. these were checked because he is a diabetic and has never had chest pain. after the episode of diabetic ketoacidosis to was again cycled and was negative by enzymes. on , the patient developed a very loud 2:3 component pericardial rub. he had not had this previously. an echocardiogram was obtained which showed an ejection fraction of 50%, a p-r gradient of 49% to 54%, moderately dilated left atrium, mild symmetric left ventricular hypertrophy, right ventricular free wall motion was normal, 1+ mitral regurgitation, and 1 to 2+ tricuspid regurgitation. there was no pericardial effusion. the etiology of the rub was unclear; although, the uremia was high on the list. given the patient's high dose of hydralazine, an antinuclear antibody was sent but was negative. the rub then disappeared and was heard intermittently throughout the following days of his hospitalization for short periods. it was felt unlikely to be given his non-st-elevation myocardial infarction in , had negative creatine kinases, and only mild troponin levels, and his echocardiogram did not show any focal wall motion abnormalities. this was felt unlikely to be viral given he was asymptomatic. this significance of this rub was unclear at this time. 8. gastrointestinal issues: the patient intermittently had nausea throughout his hospital stay. electrocardiograms remained unchanged. at first it was felt that this was exacerbated by morphine, and his medications were changed. the patient's nausea improved somewhat, and he was maintained on phenergan and zofran as needed. additionally, reglan 5 q.a.c. was added as the patient may likely have had a component of gastroparesis. protonix was added since the patient had symptoms of heartburn at home. this was discussed with the patient as it made his absorption of iron decrease, but it was decided given his nausea seemed to worsen off the protonix and improve on the protonix to continue it for now. liver function tests were sent given the patient's nausea, and his transaminases were noted to be normal as was his total bilirubin. however, his alkaline phosphatase and glutamyltransferase were noted to be elevated with an alkaline phosphatase of 327 and a glucose tolerance test of 241; however, this had been chronically elevated since . in , an abdominal ultrasound showed cholelithiasis, without evidence of cholecystitis, and no evidence of biliary ductal distention to suggest obstruction. as this seemed to be a chronic problem, it was suggested that this followed up as an outpatient. 9. orthopaedic issues: the patient was noted to have a small achilles tendon tear on magnetic resonance imaging. this needs to be followed up as an outpatient. 10. pain issues: the patient had significant pain on admission and was put on a morphine patient-controlled analgesia. however, he felt that he became confused on the patient-controlled analgesia as well as feeling an increase in his nausea. pain medications were changed around, and the current regimen that seemed to be working the best was tylenol 1 g q.6h. with oxycodone as needed. additionally, he was receiving rate morphine for breakthrough pain. nonsteroidal antiinflammatory drugs were avoided given his acute renal failure. 11. vascular issues: the patient was noted to have severe stenosis of the right peripheral graft on study. the vascular service followed the patient throughout his hospitalization and felt that a magnetic resonance angiography should be done nonurgently to evaluate this further. this was pending at this time. 12. pulmonary issues: the patient's x-rays showed significant congestive heart failure. however, he developed a cough, and an infection could not be excluded from the x-ray. therefore, ciprofloxacin was changed to levaquin to broaden coverage. initially, the patient had been on vancomycin and flagyl for coverage. 13. right upper extremity issues: on , it was noted that the patient had significant swelling in the right upper extremity, very asymmetric to the left, with pitting in the dependent portions. he had no neurologic compromise with good strength, good capillary refill, and 2+ radial pulses on that side. there was no erythema, pain, or heat. an ultrasound of the right upper extremity was performed which showed no clot of fluid collection. it was felt that the most likely etiology of the fluid was total volume overload, and the patient had previously had a graft harvested from that arm. therefore, perhaps drainage of the arm was not as good as on the left creating the asymmetry. it was treated with elevation and total body diuresis, and the swelling seemed to improve. 14. prophylaxis issues: the patient was maintained on a bowel regimen, subcutaneous heparin, protonix, and incentive spirometry. note: this covers the hospital course from to . there will be a discharge summary addendum with the rest of the hospital course prior to discharge. , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified arteriography of femoral and other lower extremity arteries other (peripheral) vascular shunt or bypass excisional debridement of wound, infection, or burn local excision of lesion or tissue of bone, other bones other incision with drainage of skin and subcutaneous tissue transfusion of packed cells injection or infusion of nesiritide diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease cellulitis and abscess of leg, except foot diabetes with neurological manifestations, type i [juvenile type], uncontrolled diabetes with renal manifestations, type i [juvenile type], uncontrolled diabetes with ketoacidosis, type i [juvenile type], uncontrolled atherosclerosis of native arteries of the extremities with ulceration other disorders of synovium, tendon, and bursa 

Answer: The patient is high likely exposed to