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: sulfa (sulfonamide antibiotics) / cipro / vancomycin / shellfish / haldol attending: chief complaint: right foot bleeding. major surgical or invasive procedure: right fifth open ray amputation esophagogastroduodenoscopy with clipping of duodenal ulcer picc line placement av fistula placement history of present illness: 60f with h/o ckd on hd t/t/s, cad s/p cabg (), stemi (), schf (ef 35%) s/p aicd placement, iddm, pvd presents with 1 day h/o bleeding from chronic right foot ulcer. pt was sent in from vascular clinic for evaluation after dressing was changed x3 for bleeding in clinic and np from asked to have ulcer evaluated in ed before returning home. she does endorse increased pain in the right foot and perhaps some green discharge from r foot in last week, but isn't sure. denies malodor, fever, chills. . in the ed, initial vitals were 96.3 80 100/36 16 96% ra. podiatry and vascular surgery were consulted in the ed. podiatry described the wound on the 5th metatarsal as clean and stable with sanguinous drainage, likely representing stable, chronic osteomyelitis of the 5th metatarsal. they debrided the ulcer and felt it was stable and not newly infected and sent samples for gram stain and aerobic/anaerobic culture. debridement led to significant bleeding which was controlled with pressure and silver cautery by vascular surgery. plain film performed which showed likely osteo in r 5th mtp and phalanx. because of left shift and renal failure, they recommended admission and to hold antibiotics until culture results. vs at transfer: 98 80 107/58 18 94%ra. . of note, the patient was admitted to the in with hyperkalemia and evidence of aocrf. she had a temp line placed for hd after her diuretic adjustment was unsuccesssful. plan was to follow up for fistula as outpatient. she was discharged off all diuretics. weight at discharge (felt to be dry) 90.6kg. . currently, she is hungry and complains of chronic l stump pain and pain in r foot. . ros: per hpi, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: cardiovascular risk factors: + htn + hl + dm # cad: stemi in with occlusion of vein graft interventions: cabg: with lima -> lad and vein graft to , 25 % at the time percutaneous coronary interventions: - stents in left anterior descending and # systolic chf - ischemic cardiomyopathy, severely reduced lv function. echo in with ef 25 - 30% # pacing/icd: right-sided aicd in place () for primary prevention given ef # iddm, eye and renal manifestations, last hba1c 9.3% () # asthma # pvd # s/p left bka # s/p right 1st toe amputation # h/o left intraductal breast cancer - s/p left mastectomy in /, now question of right-sided breast cancer, which is just being followed # s/p cholecytectomy social history: hospitalized at and/or rehab since . otherwise lives in . wheelchair-bound. son (nurse) is hcp, daughter also involved; a third son lives in . -tobacco history: none -etoh: rarely -illicit drugs: denies, but used marijuana in the past family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission exam: vs - temp 98.3 bp 105/56 hr 79 r 14 o2-sat 93% ra general - nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear, scab in l ear canal with minimal oozing around it neck - supple, no thyromegaly, no jvd heart - pmi non-displaced, rrr, nl s1-s2, ii/vi systolic murmur with no radiation to carotids/axilla lungs - ctab, no r/rh/wh, moderate air movement, resp unlabored, no accessory muscle use abdomen - nabs, firm and distended, no fluid shift, nontender, no masses or hsm, no rebound/guarding extremities - wwp, 1+ pitting edema in rle, dopplerable pulse in rle, l stump well healed. ulcer over lateral aspect of 5th digit, with mostly sanguinous drainage striking through dressing, no purulence or malodor skin - excoriations noted over trunk, arms, legs neuro - awake, a&ox3, moving all extremities, no asterixis . pertinent results: admission labs: 06:00pm blood wbc-7.9 rbc-3.17* hgb-8.2* hct-28.0* mcv-88 mch-25.9* mchc-29.4* rdw-26.4* plt ct-219 06:00pm blood neuts-75.4* lymphs-16.1* monos-5.8 eos-1.9 baso-0.7 06:00pm blood pt-16.4* ptt-33.9 inr(pt)-1.5* 06:00pm blood glucose-191* urean-31* creat-3.2*# na-133 k-3.7 cl-96 hco3-24 angap-17 06:00pm blood calcium-8.9 phos-3.7# mg-1.9 . pertinent labs: 12:11am blood wbc-10.3 rbc-2.22* hgb-5.7* hct-20.2* mcv-91 mch-25.8* mchc-28.3* rdw-28.7* plt ct-172 07:29am blood wbc-17.5* rbc-2.74* hgb-7.4* hct-25.0* mcv-91 mch-27.1 mchc-29.7* rdw-25.0* plt ct-194 01:55pm blood neuts-85.2* lymphs-8.3* monos-4.5 eos-1.5 baso-0.5 05:14pm blood hypochr-3+ anisocy-3+ poiklo-occasional macrocy-3+ microcy-1+ polychr-1+ ovalocy-occasional target-occasional 01:55pm blood hypochr-3+ anisocy-2+ poiklo-3+ macrocy-2+ microcy-1+ polychr-1+ ovalocy-3+ stipple-1+ how-jol-occasional 07:29am blood pt-29.3* ptt-37.3* inr(pt)-2.8* 04:15am blood pt-14.2* ptt-33.7 inr(pt)-1.3* 06:33am blood esr-48* 10:33am blood glucose-75 urean-61* creat-3.5* na-139 k-5.8* cl-96 hco3-19* angap-30* 02:09am blood glucose-173* urean-16 creat-1.0 na-137 k-3.6 cl-98 hco3-28 angap-15 10:00pm blood glucose-82 urean-40* creat-2.3* na-132* k-4.9 cl-101 hco3-15* angap-21* 10:33am blood alt-9 ast-33 ld(ldh)-219 ck(cpk)-39 alkphos-132* totbili-2.0* 07:28am blood alt-34 ast-153* ld(ldh)-236 alkphos-100 totbili-2.6* 12:11am blood ck-mb-3 ctropnt-0.30* 05:02am blood ck-mb-3 ctropnt-0.32* 10:33am blood ck-mb-5 ctropnt-0.37* 10:33am blood calcium-8.5 phos-5.8* mg-2.2 05:33am blood %hba1c-6.9* eag-151* 06:07am blood cortsol-18.8 05:55pm blood cortsol-39.9* 05:33am blood crp-58.1* 10:42am blood type-central ve po2-141* pco2-43 ph-7.27* caltco2-21 base xs--6 comment-green top 07:54pm blood type-mix temp-36.3 o2 flow-2 po2-27* pco2-48* ph-7.40 caltco2-31* base xs-2 intubat-not intuba 07:55am blood type- temp-36.7 po2-38* pco2-43 ph-7.37 caltco2-26 base xs-0 intubat-not intuba 10:42am blood lactate-10.1* 09:11pm urine color-dkamb appear-hazy sp -1.019 09:11pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-tr bilirub-sm urobiln-2* ph-5.0 leuks-sm 09:11pm urine rbc-<1 wbc-4 bacteri-many yeast-none epi-14 transe-<1 09:11pm urine casthy-18* 12:23am urine color-dkamb appear-clear sp -1.022 12:23am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-5.0 leuks-sm 12:23am urine rbc-<1 wbc-<1 bacteri-few yeast-none epi-0 05:55pm urine hours-random creat-179 totprot-740 prot/cr-4.1* . discharge labs: 05:30am blood wbc-9.7 rbc-2.77* hgb-8.1* hct-26.7* mcv-96 mch-29.4 mchc-30.5* rdw-24.7* plt ct-188 05:30am blood glucose-131* urean-40* creat-3.5* na-133 k-4.5 cl-94* hco3-26 angap-18 06:20am blood alt-12 ast-19 alkphos-113* totbili-1.3 05:30am blood calcium-8.6 phos-4.4 mg-2.2 10:16pm blood lactate-2.0 . microbiology: 7:03 pm swab source: foot. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): no growth. anaerobic culture (final ): no growth. swab site: toe rt 5th toe. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final ): pseudomonas aeruginosa. rare growth. piperacillin/tazobactam sensitivity testing performed by . staph aureus coag +. rare growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _______________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | cefepime-------------- 8 s ceftazidime----------- 32 r ciprofloxacin---------<=0.25 s clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=1 s <=0.5 s levofloxacin---------- <=0.12 s meropenem------------- 1 s oxacillin------------- <=0.25 s piperacillin/tazo----- i tetracycline---------- =>16 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=0.5 s anaerobic culture (final ): no anaerobes isolated. bcx (neg): , , 6/11x2, 6/16x2 bcx (pend): , , mrsa neg fecal cx: no e.coli 0157:h7 found. urine cx (): neg h.pylori ab neg . imaging: foot xray: impression: osteomyelitis involving the head of the fifth metatarsal and base of the fifth proximal phalanx. subluxation at the fifth mtp joint. abdominal/pelvis ct: impression: 1. no ct evidence of bowel ischemia without pneumatosis, mural edema and patent appearing vessels. 2. prominent retroperitoneal and pelvic nodes for which correlation with prior imaging and medical history is recommended. 3. fatty liver head ct: impression: no acute intracranial process including no evidence of acute infarction. echocardiogram (): the left atrium is moderately dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed (lvef= 35 %); there is a major component of ventricular interaction with a pressure and volume overloaded right ventricle. the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. cxr portable : mediastinal and pulmonary vascular engorgement have progressed, to the borderline of mild edema. moderate-to-severe cardiomegaly is chronic. transvenous pacer leads are unchanged in their respective positions projecting over the right atrium and the defibrillator lead over the proximal right ventricle. no pneumothorax or appreciable pleural effusion is present. dual-channel supraclavicular left central venous ends in the svc and in the region of the superior cavoatrial junction. cxr portable : there is a right-sided aicd with the distal lead tips in the right atrium and right ventricle. there is a left-sided vascular catheter with distal lead tip at the distal svc and proximal right atrium. there is also a right ij central line with the distal lead tip at the distal svc. heart size is within normal limits. there is prominence of the pulmonary vascular markings consistent with moderate pulmonary edema. there are no pneumothoraces identified. cta : impression: 1. no evidence of pulmonary embolism or acute aortic syndrome. 2. findings of congestive heart failure including moderate bilateral pleural effusion, pulmonary edema, cardiomegaly, and reflux of contrast into a dilated ivc are seen. 3. ascites is noted in the upper abdomen. cxr (portable : there is moderate cardiomegaly. transvenous pacer lead tips at the right atrium and right ventricle. right ij catheter tip is in the lower svc. there is no evident pneumothorax. mediastinal lymphadenopathy is better seen on prior ct from . there is mild vascular congestion. bibasilar opacities are a combination of atelectasis and pleural effusion. echocardiogram : the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. there is moderate global left ventricular hypokinesis (lvef = xx %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. ecg (): sinus rhythm. p-r interval prolongation. intraventricular conduction delay. st-t wave abnormalities. since the previous tracing of , the rate is faster. otherwise, unchanged. ecg (): sinus rhythm. p-r interval prolongation. left axis deviation. non-specific intraventricular conduction defect. non-specific st-t wave changes. compared to the previous tracing of there is no significant diagnostic change. pathology: fifth toe, right foot, amputation (a): bone with chronic osteomyelitis. skin and soft tissue with fibrosis. brief hospital course: 60 year old woman with esrd on hd, cad s/p cabg, systolic chf (ef 35%) s/p aicd, iddm, and pvd s/p left bka who initially presented with a bleeding ulcer of the 5th digit of her r foot, underwent amputation, then developed rising lactate, hypotension, and melena requiring admission to the micu, and was subsequently transferred to the floor for treatment for osteomyelitis. # shock/elevated lactate/melena: given melena and dropping hct, shock was thought to be hypovolemic secondary to brisk upper gi bleed, so the patient was transferred from the vascular service to the micu for further management. she was transfused 3 units of blood and hct increased from 20 to 29 and remained stable. she was initially started on peripheral neosynephrine, which was switched to levophed. at this point, her lactate increased to 10.1, patient became more somnolent, and abdomen became more firm. there was concern for ischemic colitis, so a stat ct scan was done, which showed no ischemic or infarcted bowel. surgery was consulted and did not feel that surgical intervention was indicated. her lactate eventually normalized over the next few days. on icu day 3, her melena increased, hct dropped back to 22, and her inr remained elevated at 2.8. she was transfused 4 units of prbcs without adequate increase in hct. an egd showed a nonbleeding duodenal ulcer with new clot which was clipped and injected with epinephrine. after this, she remained hemodynamically stable with stable hcts. she still remained on levophed and was + 13l. based on nicom measurements and cv02, she seemed to be in cardiogenic shock. via cvvh, 3-4 l of fluid were removed per day for several days while on levophed. patient's mental status improved and she was able to be weaned off pressors. she was empirically covered with linezolid/cefepime for septic shock for seven days, although her blood cultures did not grow any microbes. on the floor, her sbps were 90s-110s and she was mentating well. hct remained stable and guiaiac's were negative. she received 2 units of prbcs on hemodialysis (, ), per renal protocol. her hct and blood pressure on discharge were xxx and xxx, respectively. # osteomyelitis of the right 5th toe: esr and crp were elevated and radiographs of the r foot were suggestive of osteomyelitis involving the head of the fifth metatarsal and base of the fifth proximal phalanx. vascular surgery performed a two-step right fifth open ray amputation. in light of her many antibiotic allergies, the patient received empiric therapy with iv gentamicin and cefazolin, then cefepime. bone biopsies grew pseudomonas and mssa so id recommended a six week course of meropenem (->). she had a rue picc placed by ir for long-term access (the lue was avoided given plan to place av fistula in lue) and r ij was removed. her wound vac was removed while she was on the floor and per vascular recs, should continue to get dressing changes. she will follow-up with the vascular clinic in 2 weeks. she is set to complete her course of meropenem on , # esrd: cvvh was initiated while the patient was in shock. this was eventually transitioned back to hd. the patient received hd as an inpatient on a t/th/sat scheduled without difficulty. home calcium acetate and nephrocaps were continued. we gave her metoprolol on days that she did not get hd. she had an av fistula placement on her l upper extremity on . # leukocytosis: on , she developed a leukocytosis of 13.0. there was erythema, induration and yellow crust around her tunneled hd line concerning for infection thus her lines were cultured and there was no growth at the time of discharge. renal also did not feel that her hd line was infected. her wbc trended down and was in the normal range by and remained within normal limits for the remainder of her hospitalization. on discharge, blood cultures () were also negative. # chf: nodal blockade agents were held while in the micu. she was on levophed and cvvh while in shock. repeat tte showed ef 35%, worsening mr, small lv cavity, rv hypokinesis, and worsening tr (echo in also w/ dilated rv and global free wall hypokinesis). cta was negative for pe. this was thought to be secondary to volume overload. fluid was removed as noted above and her digoxin was eventually restarted. we held her carvedilol given hypotension and gave her metoprolol on non-hd days. # cad: s/p cabg lima->lad and vein graft to . no chest pain or anginal symptoms were noted during her hospitalization. her home aspirin and simvastatin were continued. # pvd: s/p multiple amputations. home plavix was continued. # dm: initially was on home glargine 15 units qhs + hiss. her bsgs remained elevated so the glargine was increased to 20 units qhs. home gabapentin was restarted. # depression/anxiety: patient w/ ams while in the icu, head ct unremarkable, and infectious w/o stable, lytes stable. felt to be icu delirium. she improved on the floor and remained a&ox3, appropriate. she experienced episodes of anxiety and her home antidepressants were restarted (buproprion and venlafaxine). by discharge, her mood had improved significantly and she reported feeling less anxious. # vision changes: on , patient reported new onset of difficulty with vision. she was tested at the bedside and found to have 20/20 near vision with full visual fields. she does have a history of myopia. she will see an ophthamologist as an outpatient. transitional issues: - should follow-up with vascular surgery - wound care for r 5th digit osteomyelitis: dressing changes - antibiotic treatment of r 5th digit osteomyelitis: meropenem q24hrs until - you are scheduled to have hemodialysis 3x/week - please check the following labs cbc with differential, bun/cr (weekly) ast/alt (weekly) alk phos (weekly) total bili (weekly) esr/crp (weekly) all laboratory results should be faxed to the infectious disease r.n.s at (. all questions regarding outpatient parenteral antibiotics should be directed to the infectious disease r.n.s at ( or to the on-call id fellow when the clinic is closed. medications on admission: bupropion hcl - (prescribed by other provider) - 100 mg tablet extended release - 1 tablet(s) by mouth once a day clopidogrel - (prescribed by other provider) - 75 mg tablet - 1 tablet(s) by mouth once a day digoxin - (prescribed by other provider) - 125 mcg tablet - 0.5 (one half) tablet(s) by mouth once a day non hd (mwfsun) gabapentin - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth once a day hydroxyzine hcl - (prescribed by other provider) - 25 mg tablet - 1 tablet(s) by mouth q8h insulin aspart - (prescribed by other provider) - 100 unit/ml solution - sliding scale insulin glargine - (prescribed by other provider) - 100 unit/ml solution - 15 units q hs simvastatin - (prescribed by other provider) - 40 mg tablet - 1 tablet(s) by mouth venlafaxine er - (prescribed by other provider) - 37.5 mg tablet - 3 tablet(s) by mouth once a day ascorbic acid - (prescribed by other provider) - 500 mg tablet - 1 tablet(s) by mouth once a day calcium acetate - (prescribed by other provider) - 667 mg tablet - 2 tablet(s) by mouth tid with meals senna 2 tabs po bid tylenol 500mg po q4h:prn pain oxycodone 5mg po q4h:prn pain colace 100mg po bid nephrocaps 1 tab po daily aspirin 325mg po daily fexofenadine 180mg po daily guaifenisin 10ml po q6h:prn cough discharge medications: 1. aspirin 81 mg po daily 2. bupropion (sustained release) 100 mg po qam 3. clopidogrel 75 mg po daily 4. digoxin 0.0625 mg po every other day (non- days: ,) 5. docusate sodium 100 mg po bid 6. glargine 20 units bedtime insulin sc sliding scale using hum insulin 7. nephrocaps 1 cap po daily 8. senna 1 tab po bid 9. simvastatin 40 mg po daily 10. meropenem 500 mg iv q24h duration: 30 days give after hd on days (). last day is 11. sarna lotion 1 appl tp qid:prn itching 12. ascorbic acid 500 mg po daily 13. calcium acetate 1334 mg po tid w/meals 14. guaifenesin ml po q6h:prn cough 15. fexofenadine 180 mg po daily 16. gabapentin 100 mg po daily 17. hydroxyzine 25 mg po q8h:prn itching 18. venlafaxine xr 112.5 mg po daily depression 19. lidocaine 5% patch 1 ptch td daily apply to back. 20. metoprolol tartrate 12.5 mg po bid give on non- days (trs, ) 21. pantoprazole 40 mg po q12h 22. outpatient lab work please check the following labs cbc with differential, bun/cr (weekly) ast/alt (weekly) alk phos (weekly) total bili (weekly) esr/crp (weekly) all laboratory results should be faxed to the infectious disease r.n.s at (. all questions regarding outpatient parenteral antibiotics should be directed to the infectious disease r.n.s at ( or to the on-call id fellow when the clinic is closed. discharge disposition: extended care facility: - discharge diagnosis: osteomyelitis bleeding duodenal ulcer heart failure chronic kidney disease cardiogenic/hemorrhagic shocking requiring pressors discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , it was a pleasure participating in your care at . you came in to the hospital for an elective right fifth toe amputation. after the procedure your blood pressure dropped and you were found to have a bleeding duodenal ulcer. this ulcer was clipped and afterwards your blood counts stabilized. you remained in the icu because although your blood pressures were low, you had a lot of fluid in your body, likely due to your kidney disease and heart failure. the excess fluid was removed by . you had an av fistula placement in your left arm near the end of your stay. you were also treated for a bone infection in your right foot with the antibiotic meropenem. you will need to continue taking meropenem by the picc line until . you initially had a wound vac over the amputated site but this was removed and you had gauze dressing that was changed twice daily. medication changes: 1) please stop taking aspirin 325mg daily and start taking a baby aspirin daily (81 mg). 2) your bedtime glargine was increased from 15 units to 20 units. 3) you should start taking pantoprazole 40 mg by mouth every 12 hours to prevent ulcers from forming in your stomach. 4) you should start taking metoprolol 12.5 mg twice daily on non- days to protect your heart 5) you should use sarna cream to prevent itching 6) you should use a lidocaine patch to help with your pain 7) you should continue meropenem antibiotics to treat your bone infection follow-up appointments: please see below followup instructions: infectious disease -- provider: , md phone: date/time: 10:30 provider: , md phone: date/time: 9:30 vascular surgery -- please follow up with dr. in two weeks time. the clinic will call you to schedule this appointment. hemodialysis-- time: 7:30 am procedure: hemodialysis venous catheterization for renal dialysis amputation of toe endoscopic control of gastric or duodenal bleeding arteriovenostomy for renal dialysis central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: acidosis hyperpotassemia end stage renal disease renal dialysis status anemia, unspecified pure hypercholesterolemia congestive heart failure, unspecified coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status personal history of malignant neoplasm of breast peripheral vascular disease, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease ulcer of other part of foot dysthymic disorder disorders of phosphorus metabolism cardiogenic shock diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin chronic systolic heart failure automatic implantable cardiac defibrillator in situ obesity, unspecified do not resuscitate status chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction other and unspecified coagulation defects diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled below knee amputation status other alteration of consciousness pseudomonas infection in conditions classified elsewhere and of unspecified site other bone involvement in diseases classified elsewhere other acute and subacute forms of ischemic heart disease, other chronic osteomyelitis, ankle and foot encounter for change or removal of surgical wound dressing 

Answer: The patient is high likely exposed to