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: latex / dilantin attending: chief complaint: sepsis major surgical or invasive procedure: endotracheal intubation mechanical ventilation central line placement skin biopsy foot biopsy history of present illness: this is a 76 year old gentleman with a history of ischemic cardiomyopathy (ef 20-30, aicd), niddm, ckd, chronic atrial fibrilation (not on coumadin because of prior fall and small head bleed) who is being transferred from the icu for sepsis of unclear origin on pressors. current course of events begins when he was admitted to back in for a nonhealing right foot ulcer after failing outpatient course of doxycycline. patient has a history of nonhealing foot ulcers (including 1 on left requiring amputation of left 5th toe in ). wound cultures negative but imaging at the time was concerning for osteomyelitis. he was eventually discharged to rehab for 6 weeks of iv vanc/unasyn. he did well during rehab and was ambulatory. only issue which was some mild diarrhea which was c diff negative and a transient skin rash with resolved with topical treatment. less than 24 hours after going home (after completing his course of antibiotics) he returned to the ed with severe malaise, chills, fever and fatigue. on presentation to the osh ed he had a temp of 100.6, was hd stable, o2 sats 96%. labs notable for wbc of 12,000 with 10% bands and with creatinine of 3.1 vs 2.5 the day prior (baseline 1.5-2.5). cxr normal. ua showed 2+ leuk est with 10-20 wbcs, budding yeast, and 1+ bacteria. he did not have an indwelling catheter. he was admitted with possible uti and started on iv cipro. since admission to hospital he has continued to clinically decline. progressive leukocytosis, fevers up to 104, and worsening . his catheter was removed (tip cultured, routine and fungal cultures still pending as of ). imaging showed evidence of osteomyelitis but overall it appeared his ulcer clinically had improved after extended antibiotics. he developed a progressive diffuse maculopapular rash with associated pruritis. he was transferred to the icu on for episodic hypotension (to sbps 60s-70s) associated with worsening labs and rash. cipro was stopped and he was started back on vanc/unasyn as well as on iv fluconazole for concerns for systemic fungal infection (recent broad spectrum antibiotics and budding yeast in urine). seen by id (dr. ). repeat c diff testing was done which was ultimately negative. hypotension was fluid responsive but after several boluses started neo (due to tachycardia/af/rvr). in the 24 hours prior to transfer (on ) he continued to clinically deteriorate. his antibiotics were changed to daptomycin, aztreonam and voriconazole given concerns for hypersensitivity reaction to prior antibiotics. all urine and blood cultures were negative. while awaiting results of c diff an abdominal ct showed gastric distention without signs of colitis or other intraabdominal source of infection. his diffuse rash persistent. renal was consulted. creatinine continued to rise and he was given further ivf (on home diuretics at baseline for cm). his blood pressures continued to decline and a right ij was placed. initial cvp was 17. he was started on neosynephrine. he continued to have af/rvr. lactate elevated at 2.7. venous saturation 79%. concern raised for aicd infection given progressive course. echo showed ef 25% and no "obvious sign of infection of cardiac hardware". no new complaints on the morning of transfer however his labs continued to decline and were notable for a wbc count of 32,000 with 45% bands and a creatinine up to 5.1. lactate unchanged at 2.6. his declining status was discussed with the family and it was decided to transfer him to a tertiary care facility. sbps prior to transfer were in the 60s-70s on neo. he had made only 30cc of urine overnight. during the 24 hours prior to transfer at osh his heart rates have mostly been in 120s, bursts (especially with fevers) to 130s-140s, resolve with treating temperature. on arrival to the micu he was severely ill-appearing and confused. he had no specific complaints but was mumbling words which were unintelligible. within 30 minutes of arrival he reported feeling much better and was alert and oriented to place. review of systems: (+) per hpi (-) denies headache, cough, shortness of breath, chest pain, chest pressure, palpitations, nausea, vomiting, diarrhea, abdominal pain. past medical history: ischemic cardiomyopathy niddm nonhealing foot ulcers af with rvr not on coumadin prior head bleed ckd baseline 1.5-2.5 cad with prior stent social history: lives at home with wife. quit smoking 25 years ago. quit etoh 30 years ago. worked as a police officer and then baliff. retired in . family history: brother died of mi physical exam: on admission to vitals: t: 97.2 bp: 81/59 p: 125 rr: o2: 94%/2l general: severely ill-apearing heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: tachycardic, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present gu: foley with minimal urine ext: 2+ edema bilaterally, cool, clampy, poorly perfused, palpable pulses bilaterally, left foot eschar, lateral aspect of right foot 5th toe ulcer, deep but without surrounding erythema neuro: alert and oriented to place on discharge: general: nad comfortable heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: irregularly irregular, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present, diffusely edematous gu: mildly swollen scrotom, foley with clear yellow urine ext: 2+ edema bilaterally, venous stasis changes, left foot eschar, lateral aspect of right foot 5th toe ulcer neuro: alert and oriented to person, date and place pertinent results: labs on admission to ============================== 03:00pm blood wbc-29.9* rbc-3.79* hgb-11.1* hct-35.8* mcv-94 mch-29.3 mchc-31.1 rdw-17.9* plt ct-177 03:00pm blood neuts-93.5* lymphs-3.5* monos-1.6* eos-1.2 baso-0.2 03:00pm blood pt-13.3* ptt-31.1 inr(pt)-1.2* 03:00pm blood fibrino-409* 03:00pm blood glucose-151* urean-88* creat-4.8* na-137 k-5.0 cl-106 hco3-14* angap-22* 03:00pm blood alt-51* ast-71* ld(ldh)-330* ck(cpk)-1751* totbili-0.3 03:00pm blood ck-mb-27* mb indx-1.5 ctropnt-0.08* 03:00pm blood albumin-3.0* calcium-6.9* phos-5.2* mg-1.8 iron-77 03:00pm blood caltibc-127* ferritn-4249* trf-98* 01:27am blood cortsol-32.6* 04:08am blood crp-greater th 03:00pm blood vanco-13.7 03:12pm blood lactate-2.7* 09:03pm blood o2 sat-98 03:54pm blood freeca-1.03* labs on discharge from =============================== 06:50am blood wbc-4.9 rbc-3.14* hgb-9.0* hct-29.9* mcv-95 mch-28.8 mchc-30.2* rdw-17.8* plt ct-173 07:35am blood neuts-83* bands-4 lymphs-2* monos-3 eos-6* baso-0 atyps-0 metas-2* myelos-0 06:50am blood glucose-144* urean-49* creat-1.9* na-144 k-4.2 cl-105 hco3-32 angap-11 03:30pm blood alt-29 ast-31 alkphos-97 totbili-0.4 02:50am blood ck-mb-5 ctropnt-0.08* probnp-* 06:50am blood calcium-7.3* phos-2.5* mg-1.9 03:00pm blood caltibc-127* ferritn-4249* trf-98* 04:32am blood type- po2-94 pco2-55* ph-7.40 caltco2-35* base xs-6 studies cxr ap radiograph of the chest was reviewed with no prior studies available for comparison. cardiomegaly is present, severe. pacemaker defibrillator lead terminates in the right ventricle. the right internal jugular line tip is at the level of superior svc. lungs are essentially clear with no appreciable pleural effusion or pneumothorax. x-ray impression: possible osteomyelitis at fifth metatarsophalangeal joint. echo conclusions moderate to severe spontaneous echo contrast is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). the right atrium is dilated. mild spontaneous echo contrast is seen in the body of the right atrium. a mobile echodensity is seen on the ra portion of the icd lead (best seen on clips 4, 67, and 95). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is severely depressed (lvef= 20 %). there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. impression: mobile echodenisty on the icd lead may be a vegetation, but cannot be distinguished from fibrin formation. no vegetations seen on the mitral, tricuspid, or aortic valves. mild mitral regurgitation. moderate tricuspid regurgitation about the icd lead. severe global left ventricular dysfunction. cxr impression: low lung volumes, no change since prior chest x-ray. cxr clinical history: patient intubated for respiratory failure, evaluate position of endotracheal tube. the tip of the endotracheal tube lies 4.8 cm from the carinal angle in a satisfactory position. there has been no significant change since the prior chest x-ray. the heart remains enlarged but failure is not currently present. ct chest/abd/pelvis impression: 1. no ct evidence for abscess. 2. atrophic kidneys with multiple round lesions which are incompletely evaluated on this study. further evaluation is recommended with non-urgent ultrasound. 3. cholelithiasis without evidence for cholecystitis. 4. arterial atherosclerosis including the coronary arteries as well as aortic valve calcifications of indeterminate hemodynamic significance. 5. calcified right thyroid nodule. if not done recently, further evaluation is recommended with ultrasound. 6. bilateral pleural effusions with adjacent atelectasis. 7. nasogastric tube terminating just below the gastroesophageal junction. advancing the tube is recommended. ultrasound upper extremity impression: 1. nonocclusive thrombus seen within the internal jugular vein bilaterally. 2. a short segment of the left cephalic vein contains occlusive thrombus. ultrasound lower extremity impression: no evidence of deep vein thrombosis in either leg. scrotal ultrasound impression: no evidence of deep vein thrombosis in either leg. ct pelvis impression: 1. no evidence of scrotal air. soft tissue stranding is noted along the left thigh and anterior abdominal wall subcutaneous tissues. 2. diffuse calcific atherosclerosis. 3. possible thickening of the rectal wall may be evaluated by digital rectal exam. cxr findings: as compared to the previous radiograph, the pre-existing predominantly basal parenchymal opacity has slightly increased bilaterally. an infectious cause for this opacity is possible. in addition, signs of moderate pulmonary edema are present. persistent blunting of the left costophrenic sinus, caused by a small left pleural effusion. the right picc line has been removed in the interval. there is unchanged evidence of a correctly positioned left pectoral pacemaker. ct head impression: 1. study limited by artifacts. 2. no acute hemorrhage. 3. large left posterior cerebral artery territory infarction, which appears to be chronic. extensive chronic small vessel ischemic disease in the supratentorial white matter. while no ct evidence of an acute major vascular territory infarction is seen, mri would be more sensitive for an acute infarction, particularly in the setting of extensive chronic changes. ultrasound uppter extremity impression: 1. new left basilic partially occlusive thrombus adjacent to an existing picc. 2. unchanged non-occlusive thrombus within the left cephalic vein. 3. unchanged small non-occlusive thrombus within the left ij. pathology skin biopsy specimen submitted: left abdomen procedure date tissue received report date diagnosed by dr. /lo?????? diagnosis: skin, left abdomen: patchy vacuolar interface change, spongiosis with focal subcorneal necrosis, and superficial to mid-dermal perivascular lymphocytic infiltrate with abundant eosinophils (see note). note: no bacteria, fungi or acid fast bacilli are seen on brown-brenn, gms, and afb stains. immunostains for cmv, hsv1 and 2, and vzv are negative. no vasculitis or superficial pustulosis is seen. in the described clinical context, the findings are most suggestive of a systemic hypersensitivity reaction, as to a drug. clinical: specimen submitted: left abdomen. clinical: 76 yr. old male with sepsis and on many antibiotics for past 6 weeks with morbilliform rash. please evaluate for drug hypersensitivity, agep, dress, vasculitis, infectious, toxic erythema. gross: the specimen is received in a formalin filled container labeled with the patient's name " ", medical record number and date of birth. specimen consists of a punch of skin measuring 4.4 cm in diameter excised to a depth of 0.8 cm. the surface of the skin is remarkable for an irregularly-shaped light pink papule measuring 0.3 x 0.3 cm. the margin is inked in blue. the specimen is bisected and entirely submitted in cassette a. brief hospital course: this is a 76 year old gentleman w/ a hitory of cardiomyopathy, af not on coumadin, recurrent nonhealing ulcers and recent osteomyelitis transferred from with severe sepsis w/o definite source. active issues #. shock: the pt was transferred to micu in shock, likely due to combination -of septic and cardiogenic etiologies. he was treated empirically for sepsis with broad spectrum antibiotics including vancomycin and meropenem for 7 days. weaned off all pressors on . no source of infection was identified and antibiotics were discontinued on . he was afebrile and hd stable at the time of transfer to medicine floor. the etiology of his sepsis was not identified. at the time of discharge, pt had been stable off of antibiotics and was afebrile without leukocytosis. # ischemic cardiomyopathy: ef 20-30% on echo (). a nstemi prior to transfer to cannot be ruled out given slightly elevated ckmb and troponin. lisinopril, and spironolactone were held. asa and plavix were continued. his statin was restarted. he was given iv lasix for volume overload and responded well to doses of 120 iv. he was put on metoprolol 12.5 mg . his lisinopril and spironolactone were still on hold at the time of discharge because of unstable kidney function. on telemetry, there has been frequent asymptomatic pvc and nsvt. # /ckd: patient developed acute renal failure and required cvvh while in the micu in the setting of hypotension and shock likely related to atn. renal was consulted, his urine sedimentation showed granular casts without muddy brown casts. he was not hyperkalemic, acidotic or uremic. at the time of transfer to medicine floor he did not need further cvvh though he was oligouric making 300cc or urine on the day prior to transfer. in the setting of low free water intake he became hypernatremic with a free water deficit. the hypernatremia and uop improved with diuresis and d5w resuscitation. his creatinine was stable around 2 at time of discharge. # respiratory failure: he was intubated for inadequate compensation for metabolic acidosis/concomitant respiratory acidosis. he was extubated on . upon transfer to he was breathing well on 3l o2. on the medical floor, he occasionally required 2l nc to maintain his o2 saturation above 90%. he had one night of desaturation into the 70s when sleeping which required transfer to the micu. this was most likely secondary to chronic air trapping with obesity hypoventilation and pulmonary edema as his lasix had been held in the setting of increased diarrhea from cdiff. his oxygenation improved with diuresis and cpap, and he was transferred back to the floor. sleep medicine evaluated the patient who recommended bipap 10/5 when sleeping. # upper extremity non-occlusive thrombi: reported history of cns bleed, according to the pcp, had a spontaneous intracranial hemorrheage. anticoagulation was held given history of spontaneous intracranial hemorrhage. upper extremity us showed multiple ij thrombi and a thrombus at the picc site. picc was d/ced, left arm swelling decreased. vascular was consulted about possible svc filter but recommended against placement at this time. he is scheduled for outpatient vascular follow up. # c. diff: patient was noted to have diarrhea on . cdiff was positive. he was started on po vancomycin. he remained afebrile without leukocytosis and his diarrhea improved. he was discharged with plans to complete a 14 day course of po vancomycin (last day ). # pusutular drug reaction: the pt developed a body rash at osh, although exact cause of the reaction was unclear. review of discharge medications from life care was unrevealing as there were no new medications at the time of discharge. however, it is unclear which meds were given while he was at rehabilitation. he completed a course of clobetasol propionate 0.05% ointment with marked improvement. per dermatology, this is consistent with acute generalized exanthematous pustulosis (agep), a drug reaction, although unclear which medication at the rehab was the culprit. if recurs, will need to follow lft and eos. rash had resolved by discharge. new erythematous blanching rash on abdomen and thighs started on , is stable and likely from irritation. this will need to be monitored at rehab. #. atrial fibrilation with rvr: cardiology was consulted and recommended rate control with metoprolol and continued diuresis. he was maintained on telemetry. he was not anticoagulated for afib as he had hx of spontaneous intracranial bleeding. # osteomyelitis: pt has a history of unhealing ulcers secondary to pvd. amputation was suggested, but declined by the patient in the past. he developed osteomyelitis about 2 months prior to admission, and treated with 6 wk course of vanco/zosyn for right non-healing ulcer. imaging at osh showed slight worsening vs prior. at , on , plain film of the right foot was concerning for osteomyeltiis involving right #5 metatarsal. esr and crp on unremarkable. podiatry did a biopsy through the wound, cultures were negative (on antibiotics). podiatry ecommended local wound care, wet to dry dressings, off-loading multipodus boots. weight bearing status: pwbat to right heel. he will need to follow up with podiatry after discharge. # ischemic toes: the pt was noted to have necrotic toes concerning of ischemia in setting of coming off pressors. his non invasive aterial study on showed monophasic dp on r and triphasic pedal pulses on l. vascular surgery was consulted and felt that observation with follow up as an outpatient was appropriate. # agitation/ams: this occured while pt was on the floor and differential included hypoglycemia vs hypernatremia vs ongoing occult infection. his nighttime insulin dose was decreased. hypernatremia was treated with d5w. respiratory distress also a factor which improved during the day with stimulation and family members. # swollen painful scrotum: concerning for fournier's gangerene, urology consulted and found no evidence of fournier's on u/s or ct. he responded to repositioning. this was likely due to edema from fluid overload. # dm: on glargine and insulin sliding scale. # communication: wife c h # code:dnr (but icd active), okay to re-intubate transitional issues: ======================== # code status: dnr (with icd active), ok to intubate # pending studies -blood culture: x2 - ngtd # medication changes - stopped aldactone - stopped atenolol - stopped allopurinol - stopped ambien - stopped hctz - stopped glyburide - changed metoprolol succinate to tartrate - started lantus and sliding scale insulin - started vancomycin po - started nystatin powder - started calcium carbonate as started - started lidocaine patch #transitional issues -thyroid ultrasound as per ct above -pt has latex allergy -diuresis as tolerated to maximize his volume status (has responded to lasix iv 120 mg boluses) -electrolyte monitoring -strict is/os, daily weights -please remove foley -cpap -complete treatment of c.diff (last day is ) -monitor rash on abdomen -physical therapy -wound care site: bilateral feet wounds (r>l) description: -circular ulcer on plantar side of r 5thmtp, no signs of infection-superficial pressure ulcer on l lateral heel care: right foot: wet to dry dressing, change daily.left foot: care per pressure ulcer protocol site: sacral and coccyx skin breakdown description: there is mild maceration and there is a darker area on the left gluteal concerning for possible deep tissue injury. the pt reports pain to the area. the entire area is approx 5 x 7cm. the pt is incontinent of stool and this may be contributing to the skin breakdown - there is no perianal dermatitis or skin breakdown. the skin impairment noted above may be related to pt's drug rash and worsened by incontinence and pressure. care: cleanse skin gently after each bm using aloe vesta foam and soft disposable towelettes avoid rubbing, instead pat tissues gently to avoid increased pain apply thin layers of critic aid across entire perineal and gluteal tissues no need to reapply after each bm, reapply after 3rd cleansing only -needs cardiology follow up for heart failure management -needs vascular follow up for ischemic toes and upper extemity clot -needs sleep follow up for sleep study and management of osa -consider pfts and pulmonary follow up -needs ultrasound of renal masses seen on ct -needs ultrasound of calcified thyroid nodule seen on ct medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral : prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral : prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily discharge medications: 1. collagenase ointment 1 appl tp daily please apply to ulcers with dressing changes. 2. docusate sodium (liquid) 100 mg po bid:prn constipation 3. glargine 16 units bedtime insulin sc sliding scale using novolog insulin 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. heparin 5000 unit sc tid 7. miconazole powder 2% 1 appl tp qid:prn fungal areas 8. senna 1 tab po bid 9. albuterol inhaler 1 puff ih q6h:prn wheezing 10. ascorbic acid 1000 mg po daily 11. acetaminophen 650 mg po q6h:prn pain 12. pravastatin 40 mg po daily 13. calcium carbonate 1000 mg po qid:prn heartburn 14. vancomycin oral liquid 125 mg po q6h started 15. sodium chloride nasal spry nu qid:prn dry nasopharynx 16. lidocaine 5% patch 1 ptch td daily apply lower back/sacrum near area of pain 17. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 18. metoprolol tartrate 12.5 mg po bid hold for sbp<100 hr<60 19. furosemide 120 mg iv bid:prn volume overload 20. glucagon 1 mg im q15min:prn hypoglycemia protocol discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis - sepsis - congestive heart failure (systolic, acute on chronic, ef 20-30%) - nonhealing foot ulcer secondary diagnosis - diabetes mellitus - atrial fibrillation - chronic kidney disease - drug rash discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear mr. , it was a pleasure taking care of you at the . you were transferred from an outside hosiptal with sepsis, which is a serious illness that happens when an infection affects the whole body so your heart had trouble to supply your organs. after aggressive medical management including strong antibiotics, blood pressure medications, respiratory support, cardiovascular support, you were able to recover from the serious illness. the source of your infection was not identified despite our best effort in multiple radiology scans, and labs tests. however, due to your serious condition, a number of your organs have been affected. your kidney was damaged for lack of blood supply. fortunately, it has improved and you did not require dialysis. your toes turned blue because of lack of blood supply. secondly, you came in with a diffuse body rash that we thought was caused by a drug reaction. the drug that might have caused your rash was never identified. your rash improved with a steroid cream. also, in the search of your infection source we found multiple clots in your upper arms where the iv lines previously were placed. you did not have occlusion of your arm vessels. we did not give you blood thinning medications given your adverse reaction to coumadin in the past. you also had an infection of your bowel with a bacteria called clostridium difficile which causes diarrhea. it was treated with oral vancomycin which you will continue until . you also had trouble breathing which required a transfer to the medical icu for one night. you were placed on cpap breathing machine and given more lasix which improved your symptoms and you were able to come back to the medical floor. you also received intravenous medication to remove fluids from your body. we were able to make some progress. however it appears that this process will take some time. we think that you may benefit from further diuresis in a rehab setting, where more targeted nursing and physical therapy could also be provided. please note that a number of changes have been made to your medications. please follow up with your providers as scheduled. you will need to be seen by cardiology and vascular surgery providers. you should also follow up in the sleep clinic to help manage your sleep apnea. followup instructions: department: vascular surgery when: tuesday at 10:30 am with: , md building: lm campus: west best parking: garage we are working on a follow up appointment for your hospitalization in pulmonary sleep medicine. it is recommended you be seen within 1 month of discharge. the office will contact you with the appointment information. if you have not heard within a few business days please call the office at . department: cardiac services when: tuesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances hemodialysis excisional debridement of wound, infection, or burn closed biopsy of skin and subcutaneous tissue diagnoses: anemia, unspecified acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified septicemia severe sepsis candidiasis of other urogenital sites atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes paroxysmal ventricular tachycardia ulcer of other part of foot other specified forms of chronic ischemic heart disease constipation, unspecified chronic kidney disease, stage iii (moderate) other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other shock without mention of trauma intestinal infection due to clostridium difficile other complications due to other vascular device, implant, and graft morbid obesity pressure ulcer, lower back dermatitis due to drugs and medicines taken internally do not resuscitate status hyperosmolality and/or hypernatremia acute on chronic systolic heart failure atherosclerosis of native arteries of the extremities with gangrene delirium due to conditions classified elsewhere diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled unspecified osteomyelitis, ankle and foot fitting and adjustment of automatic implantable cardiac defibrillator pressure ulcer, unspecified stage unspecified drug or medicinal substance causing adverse effects in therapeutic use edema of male genital organs body mass index 40.0-44.9, adult obesity hypoventilation syndrome acute venous embolism and thrombosis of superficial veins of upper extremity 

Answer: The patient is high likely exposed to