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: doxycycline / erythromycin base / ibuprofen / indomethacin / lovastatin / pravastatin / brilliant blue fcf / penicillins / latex / tetracyclines / nsaids / hmg-coa-r inhibitors / macrolides / statins-hmg-coa reductase inhibitors / ketolides attending: chief complaint: s/p nstemi major surgical or invasive procedure: cardiac catheterization history of present illness: patient is an 87 year old woman with pmh of dm, htn, and afib s/p ppm admitted to on with non-healing gangreonous right fourth toe for consult regarding amputation. patient was started empirically on vancomycin, levofloxacin, and flagyl until wound culture grew mrsa, and levofloxacin and metronidazole were d/c'd. . the morning prior to admission, at , patient developed sob without cp or ekg changes and was diuresed with relief of sob. later in the day, she developed chest tightness and troponins bumped 1.2/1.26/1.04. the patient was placed on heparin drip along with plavix and aspirin. tte showed possible anterior wall dysmotility. the morning of admission she developed recurrent left shoulder pain relieved with ntg and morphine and twi on ekg. it was decided to transfer patient to for cardiac catheterization. . vs on transfer: 132/68 hr 78 r 18 sat 97% 2lnc. 0/10 pain. in the cath lab, patient was noted to have 3 vessel disease. cardiac surgery was consulted and recommended cabg on monday. patient was transferred to the floor in good condition, complains of a mild headache, denies any chest pain or sob. . on review of systems, she complains of chronic nonproductive cough, decreased sensation in her feet, claudication, and chronic diarrhea self treated with lometil, and increased urinary frequency. she denies any prior history of stroke, tia, deep venous thrombosis, or pulmonary embolism. she denies recent fever or chills. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: +diabetes, ?dyslipidemia, +hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: afib s/p ppm 3. other past medical history: retinopathy neuropathy lvh afib s/p ppm for sick sinus syndrome gerd djd anxiety osteoporosis pernicious anemia s/p c-section x2 and hysterectomy cataracts vulvar condylomata diverticulosis social history: -lives at senior living. -tobacco history: never -etoh: none -illicit drugs: never -herbal medications: none family history: father and 2 brothers with mi. otherwise noncontributory physical exam: admission physical exam vs: t=98.7 bp=134/49 hr=61 rr=16o2 sat=98% general: thin elderly woman in nad. oriented x3. mood, affect appropriate. heent: anicteric sclerae. perrl, eomi. dry mucus membranes. nares and oropharnxy clear. neck: supple without lad, thyromegaly or jvd. cardiac: normal s1, s2. ii/vi systolic murmur over left sternal border. no s3 or s4. lungs: resp were unlabored, patient lying on back post cath. auscultation of anterior chest was clear. abdomen: soft, ntnd. no hsm or tenderness. normoactive bs extremities: right foot dressed up to ankle. bandage clean. no cce noted on left foot skin:stasis dermatitis noted over left foot, well healed midline abdominal scar. no ulcers or scars noted. pulses: right: radial 2+ left: radial 2+ dp 0 pt 0 . discharge exam: gen: nad neck: jvp flat cv: irregular rate and rhythm, no m/r/g appreciated pulm: no crackles, good air movement, resp unlaboured abd: nabs, soft, non-tender even with deep palpation. ext: no edema. wound on right foot largely unchanged, lambs wool between toes at site of kissing ulcer sticking to ulcer site this am. eschar material coming loose from toe with minimal drainage. toe much less ttp. feet warm. dopplerable pulses. neuro: a/ox3, non-focal pertinent results: admission labs 01:42pm blood wbc-10.1 rbc-3.31* hgb-10.4* hct-29.5* mcv-89 mch-31.3 mchc-35.1* rdw-13.2 plt ct-165 01:42pm blood neuts-75.6* lymphs-16.6* monos-3.5 eos-3.8 baso-0.5 01:42pm blood pt-14.8* inr(pt)-1.3* 01:42pm blood glucose-133* urean-20 creat-0.9 na-140 k-3.5 cl-103 hco3-28 angap-13 01:42pm blood alt-15 ast-32 ck(cpk)-65 alkphos-77 amylase-27 01:42pm blood ck-mb-5 ctropnt-0.11* 01:42pm blood albumin-3.1* 01:42pm blood %hba1c-7.9* eag-180* pertinent labs 04:10am blood esr-46* 01:42pm blood ck-mb-5 ctropnt-0.11* 04:10am blood ck-mb-4 ctropnt-0.08* 04:10am blood crp-78.5* 04:10am blood %hba1c-8.2* eag-189* 02:42pm blood lactate-2.4* 09:17pm blood lactate-1.2 05:46am blood lactate-0.8 discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:30 9.3 3.66* 11.2* 33.7* 92 30.7 33.4 14.3 207 renal & glucose glucose urean creat na k cl hco3 angap 06:30 183*1 16 0.9 139 4.8 104 26 14 pertinent studies # cardiac cath 1. selective coronary angiography of this co-dominant system revealed three vessel coronary disease. the lmca had a 20% distal lesion. the lad had 70% proximal stenosis with a very tortuous mid-distal vessel with mid 70 and 60% stenoses. there was moderate stenosis of major branching s2 and apical collaterals to the rpda with retrograde filling of the distal rca upstream of the rpda. the lcx had a 65% proximal lesion and an 80% complex mid-vessel lesion at the bifurcation of the major om1. there was mild-moderate diffuse disease in the av groove lcx after om1 to 50%. ther ewas a modest caliber lpl1 and lp2, a small pda and collaterals to the rpda. the rca had a proximal 50% lesion and a mid occlusion. 2. resting hemodynamics revealed mild pulmonary arterial hypertension, mild elevation of the lvedp, no end diastolic gradient. the peak to peak gradient across the aortic valve was 4mmhg (mean of 14mmhg) on simultaneous recording of the lv and ao, confirmed on left heart pullback. the patient had a low calculated cardiac output with calculated 1.2cm2 by and 0.9cm2 by haki, but dobutamine was not administered given recent myocardial infarction and history of atrial fibrillation. 3. left ventriculography was not performed. heavy mitral annular calcification and calcification of the aortic knob were noted. final diagnosis: 1. three vessel coronary artery disease. 2. moderate systolic ventricular dysfunction. 3. mild pulmonary arterial hypertension. # echo the left atrium is mildly dilated. the left atrium is elongated. the estimated right atrial pressure is 5-10 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with hypokinesis of the distal ventricle and apex. the remaining segments are hyperdynamic (lvef = 40-45 %). a left ventricular thrombus was not seen but cannot be excluded given poor apical windows. right ventricular chamber size and free wall motion are normal. there is an elongated echodense structure in the right ventricular apex (0.8 x 1.7 cm, clip ). this most likely represents a prominent moderator band and less likely a mural thrombus given preserved rv function. in addition, a mass attached to the rv lead cannot be excluded. the aortic valve leaflets (3) are mildly thickened with mild aortic stenosis ( 1.2-1.9 cm2). no aortic regurgitation is seen. there is severe mitral annular calcification. there is mild functional mitral stenosis (mean gradient 7mmhg) due to mitral annular calcification. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with mild-moderate focal dysfunction c/w cad. severe mac with at least moderate mitral regurgitation. mild aortic stenosis based on visual assessment and continuity equation (transvalvular aortic velocities and gradients are not increased). right ventricular echodensity as described above. moderate pulmonary artery systolic hypertension. # cxr the tip of the swan-ganz catheter is in the proximal part of the right main pulmonary artery. there is no evidence of a pneumothorax. the heart is enlarged, but there is no failure. a dual-chamber pacemaker is present. impression: tip of swan-ganz catheter in proximal right main pulmonary artery. no pneumothorax. # cxr in comparison with the study of , there is evidence for increased pulmonary venous pressure, consistent with the clinical impression of pulmonary edema. there has been development of right and probably a small left pleural effusion. pacemaker device remains in place and the right ij swan-ganz catheter tip is in the right pulmonary artery. # cxr (portable) the lungs are well expanded and show mild bilateral interstitial and focal airspace opacities. in addition, there are more confluent opacities in both lower lobes. the cardiac silhouette is enlarged, unchanged. the mediastinal silhouette and hilar contours are normal. a sheath is noted in the right internal jugular, terminating in the proximal svc. a left-sided pacer terminates with its leads in the right atrium and right ventricle. there is a moderate right and small left pleural effusion. no pneumothorax is present. impression: interval improvement in now mild pulmonary edema. unchanged right moderate and small left pleural effusion. # foot findings: no prior images. calcification in small vessels is consistent with diabetes. there is soft tissue swelling about the fourth digit, though no definite evidence of erosions or lucencies on this limited study. if there is a high clinical suspicion for osteomyelitis, mri could be helpful. # lower extremity arterial studies right: the right abi is 0.55/0.33 at pt and dp respectively. the right femoral, superficial femoral, popliteal, posterior tibial waveforms are all monophasic. the dorsalis pedis waveform is nearly aphasic. pvrs show a significant dampening between the thigh and calf and again in the distal areas with aphasic metatarsal tracing. the digital pleth waveforms are flat. left: the left abi is 0.34/0.35 at pt and dp respectively. doppler waveforms are monophasic at all levels with severe dampening at the dorsalis pedis. the pvrs show severe dampening at ankle and flat tracing at the metatarsal level. digital plethysmography is flat. impression: multilevel occlusive disease involving inflow and tibial vessels bilaterally. forefoot ischemia is severe bilaterally. # lower extremity catheterization final diagnosis: 1. severe right lower extremily multilevel disease with re-occlusion of the previously angioplastied right dsfa-popliteal segment, severe right tpt disease and severe diffuse right pt disease with occlusion of the right at and peroneal arteries with minimal flow to the right foot. 2. successful pta and stenting of the right dsfa-popliteal with deployment of three overlapping zilver stents. 3. successful pta of the pt and tpt with a 2.0mm balloon. # lower extremity arterial studies findings: monophasic doppler waveforms were seen bilaterally at the femoral, popliteal, posterior tibial and dorsalis pedis arteries. the right abi was 0.98 and the left abi was 0.42. pulsed volume recordings showed markedly decreased amplitudes on the left side, with flat tracing at the left ankle, metatarsal, and digits. comparison: compared to the noninvasive arterial study obtained on , there has been improvement in the right abi and right ankle and metatarsal pulsed volume recordings. impression: 1. bilateral inflow arterial disease to the lower extremities. 2. mild outflow arterial disease in the right lower extremity, which has significantly improved since the last study of . 3. severe outflow arterial disease component in the left lower extremity. brief hospital course: 87 y.o woman with history of afib, sick sinus s/p pacemaker placement, hypertension transferred from outside hospital for cardiac cath, and was found to have three vessel coronary artery disease and gangrenous r 4th toe. . active issues # coronary artery disease patient was transferred from outside hospital for concerns of nstemi. cardiac catheterization was performed immediately upon arrival and showed three vessel coronary artery disease with moderate systolic ventricular dysfunctionn and mild pulmonary arterial hypertension. the definitive treatment for her condition is either cabg or high risk angioplasty. however, her condition was unstable to pursue either modality. per discussion with patient herself and family, a decision of medical management was made. patient was treated with aspirin 325 mg daily, metoprolol succinate xl 200 mg daily and fondaparinux 2.5 mg for 8 days. there were no increase in ck-mb, but troponin remained marginally positive throughout this hospitalization. patient was briefly treated for chest pain initially, but remainly asymptomatic afterwards. outpatient issues - started plavix, not on coumadin, s/p stenting of peripheral artery . # atrial fibrillation: during the first night, patient developed atrial fibrillation with rvr and chest pain. she was given her home dose of verapermil, po metoprolol, two sublingual nitroglycerine as well as an additional 5 mg iv metoprolol for rate control. shortly afterwards patient developed hypotension with sbp in 60s. she was then transferred to ccu for treatment of cardiogenic shock (see below). she returned to sinus rhythm on the second day. her atrial fibrillation recurred again later during the hospitalization, but she remained hemodynamically stable. we held her verapermil, but continued her on 100 mg metoprolol xl daily for rate control. . # cardiogenic shock: patient was found to be in cardiogenic shock on the second hospital day. this potentially could have been precipitated by patient's atrial fibrillation and her likely markeded dependence on her atrial kick due to significant mitral stenosis from her mitral annulus calcification as well as decreased contractility from nstemi. she was treated in ccu with fluid, and dopamine/levophed drip. patient was successfully weaned off pressor within 24 hours, and remained hemodynamically stable aftewards. echo on showed mild symmetric left ventricular hypertrophy with mild-moderate focal dysfunction c/w cad, with lvef 40-45%. . # pulmonary edema patient developed acute shortness of breath with a drop of o2 saturation to 80s on the next morning after successful treatment of cardiogenic shock. a stat chest x-ray showed pulmonary edema. she received iv lasix, and responded well to the diuresis. her losartan was not continued during her hospital stay because of uptitration of the metoprolol. please restart at 25 mg daily in a few days. furosemide 20 mg daily was started during this hospitalization. her discharge weight was 56.9kg. . # gangrenous right foot patient has a nonhealing ganrenous ulcer in her right foot, which started about nine month ago, and was evaluated at the osh prior to admission at our hospital. culture from osh grew mrsa which was sensitive to genatmycin, tetracycline, bactrim and vancomycin. a foot x-ray showed tracking to the bones consistent with osteomyelitis. given the high likelihood of polymicrobial infection in the setting diabetic foot ulcer, patient was received triple coverage of vancomycin, ciprofloxacin and flagyl during this hospitalization per id consult. patient had an arterial study, which showed severe outflow arterial disease component in the left lower extremity. patient underwent popliteal catheterization with three stents placed. her dp pulses were dopplerable all the way to the distal toe, and vessel patency was confirmed on a repeat arterial study. patient was reevalauted by id, who recommend finishing a 6 week course of vancomycin, ciprofloxacin and flagyl. a picc line was placed on the day of discharge. outpatient issues: - start vancomycin 1250 mg iv qd for 6 weeks - start ciprofloxacin 500 mg po bid for 6 weeks - start metroniadazole 500 mg po tid for 6 weeks - patient will be followed by id in two weeks. . chroinic issues # diabetes mellitus patient has a documented history of type 2 diabetes, and was treated with sliding scale insulin during this hospitalization. her hemoglobin a1c was 8.2. . transitional issues - patient declared a code status of dnr/dni - lenthy discussion was made with both the patient and her family regarding the the goal of care. patient apppears to value quality of life, and independence; and therefore may not want invasive therapy. palliative care team was involved in her care this hospitalization. the goal of care is expected to change as patient's condition changes. medications on admission: transfer medications: . ntg 0.4 sl prn asa 325 daily vicodin q4 prn heparin gtt lexapro 10 daily latanoprost eyedrops bactrim ds tylenol 650 q6 prn verapemil 240 daily metoprolol xl 25 daily losartan hct 50/12.5 pill daily glimepiride 4 mg zetia 10mg daily colace 100 daily digoxin 0.125 daily plavix 75 daily humalog sliding scale discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual q5min () as needed for chest pain: no more than 3 tablets for each episode. 3. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 4. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain >6: do not exceed 4 grams of acetaminophen per day. 5. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 6. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime): both eyes. 7. metoprolol succinate 100 mg tablet extended release 24 hr sig: two (2) tablet extended release 24 hr po daily (daily). 8. glimepiride 4 mg tablet sig: one (1) tablet po twice a day. 9. humalog 100 unit/ml solution sig: 0-14 units subcutaneous four times a day: before meals and qhs as per sliding scale. 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): take daily until dr. tells you to stop. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 6 weeks: stop on . 13. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 6 weeks: last day . 14. collagenase clostridium hist. 250 unit/g ointment sig: one (1) appl topical daily (daily): to necrotic area on toe. 15. diphenoxylate-atropine 2.5-0.025 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for diarrhea. 16. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 17. vancomycin 500 mg recon soln sig: 1250 (1250) mg intravenous q 24h (every 24 hours) for 6 weeks: last day . please check trough before dose on and adjust vanco dose as needed. 18. zetia 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: atrial fibrillation with rapid ventricular response cardiogenic shock acute systolic dysfunction severe coronary artery disease diabetes mellitus right toe ulcer with osteomyolitis and gangrene peripheral artery disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure caring for your at . you were transferred from for a cardiac catheterization which showed severe blockages in your heart arteries. the decision was made by the team, you and your family to treat these blockages with medicines instead of surgery. you developed a rapid heart rhythm called atrial fibrillation that caused a low blood pressure and shock. in this setting you also had fluid overload and needed to take diuretics to remove the fluid. your right toe ulcer was more painful and you underwent a peripheral catheterization and received 3 stents to open the artery in your leg to increase the blood flow to your toe. this seems to be working and your circulation to the foot is much improved. you will need daily dressing changes and intravenous antibiotics to treat the infection in your toe bone until . a picc line was placed on for the antibiotics. you will need to be seen by the infectiious disease team and dr. in a few weeks. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . we made the following changes to your medicines: 1. stop taking verapamil, losartan hct, colace and digoxin. 2. start taking ciprofloxacin, flagyl and vancomycin for the infection in your toe bone, you will need these intravenously for 6 weeks. 3. start taking pantoprazole for your stomach 4. start taking lomotil for the diarrhea 5. use collagenase on your toe to remove dead tissue 6. start lasix to prevent fluid from accumulating 7. increase metoprolol to 200 mg daily to prevent a rapid heart rate. followup instructions: id: department: infectious disease when: friday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage department: infectious disease when: friday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage . cardiology: department: cardiac services when: friday at 1 pm with: , md building: sc clinical ctr campus: east best parking: garage md, procedure: venous catheterization, not elsewhere classified combined right and left heart cardiac catheterization coronary arteriography using two catheters angioplasty of other non-coronary vessel(s) arteriography of femoral and other lower extremity arteries aortography pulmonary artery wedge monitoring insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) insertion of three vascular stents procedure on two vessels diagnoses: subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery esophageal reflux congestive heart failure, unspecified unspecified essential hypertension atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes ulcer of other part of foot cardiogenic shock diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled osteoporosis, unspecified cardiac pacemaker in situ methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site acute systolic heart failure atherosclerosis of native arteries of the extremities with gangrene diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled background diabetic retinopathy acute osteomyelitis, ankle and foot other bone involvement in diseases classified elsewhere 

Answer: The patient is high likely exposed to