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: vancomycin attending: chief complaint: hypotension, decreased uop major surgical or invasive procedure: tunneled line placement history of present illness: mr is a 62 year old male with hx of esrd from diabetic/hypertensive nephropathy, s/p lrrt in on double immunosuppression with cyclosporine and prednisone (b/l creatinine 2.2), who is sent to from rehab facility today for hypotension, decreased urine output and acute on chronic renal insufficiency. he was being treated for a soft tissue infection at rehab (abx unknown) and finished the antibiotics 5 days ago (saturday). over the past serveral days he has been hypotensive with orthostatic changes (sbp decreased from 118 to 80 from supine to sitting). he has had decreased urine output and, though usually continent of urine, has required straight catheterization to obtain gradually decreasing of quantities of urine over the past three days. he was recvently hospitalized at for leg weakness which the patient states has been ongoing. he was discharged to rehab with a diagnosis of steroid myopathy since he has been on prednisone 10 mg for years. cyclosporine decreased (50 mg to 25 mg ) a few days ago per patient. review of systems: currently, the patient denies dyspnea, chest pain, palpitations, fevers, chills, abdominal pain, nausea, vomiting, lightheadedness, dizziness, tingling or numbness. he has limited strength in both legs. he does usually urinate, but has required straight catheterization over the past couple of days; he thinks his overall urine output has decreased. full 10-system review otherwise negative except as noted above in the ed, initial vs were 97.2 78 93/57 99%. initial labs were notable for na 131, hco3 16, bun 150, cr 6.4 and hct 28.6. ua showed 178 rbc and 14 wbc. cxr showed severely enlarged heart but no acute pulmonary process. ekg showed afib, rbb, and indertemniate axis. echo showed longstanding pericardial effusion without tamponade. patient received regular insulin for glc of 295 and 2 l ns. bp responded to small boluses 250cc. past medical history: 1. esrd s/p renal transplant: patient believes this was secondary to diabetes and hypertension - dialysis from ~'-' - left fistula ~95 - liver donor transplant ' (sister with 6/6 match) - admitted () with arf; biopsy was consistent with atn. during this admission, cellcept was discontinued. 2. diabetes mellitus: (+)nephropathy and neuropathy; denies retinopathy 3. hypertension 4. hypercholesterolemia 5. history of tia (): presented with left leg weakness; mri showed "tia". 6. osteoarthritis, left knee 7. history of gout (); no episodes since that time 8. history of lumbar disc herniation 9. history of conjunctivitis () 10. history of bell's palsy (in his early 30s) 11. s/p right hip fracture with repair with 3 screws 12. s/p right 3rd toe distal amputation for non-healing infection 13. s/p vasectomy social history: previously owned a catering truck business. divorced; raised two sons. currently lives alone in . denies tobacco, alcohol, drugs. family history: father died of pancreatic cancer at 86; he also had dm. mother alive at 95 with alzheimers. physical exam: admission physical exam: vitals: 97.2, 86, 20, 94/48, 100% ra general: awake, alert, oriented, pleasant, well-nourished adult male in nad heent: no conjunctival icterus, injection or pallor, mmm, op clear, no exudates neck: obese, supple, no jvd lungs: mildly decreased breath sounds at bilateral bases. no wheeze or rhonchi cv: non-distant heart sounds, rrr, normal s1/s2, no rubs or murmurs abdomen: soft, nt/nd, +bs, no rebound/guarding, no organomegaly ext: warm, scattered skin tears and wounds, 1+ symmetric bilateral pitting edema in lower extremities neuro: sensation to light touch intact throughout. able to move all extremities at will. 4/5 strength in lower extremity muscle groups (proximal > distal), symmetrically discharge pe: vs: t 98.2, tm 98.3, hr 60-70s, bp 140/52, rr 20, 96-100% ra general: chronically ill appearing male, lying in bed, a&ox3, in nad heent: sclera anicteric cardiac: distant heart sounds, rrr, no murmurs appreciated, unable to appreciate jvp secondary to body habitus lungs: ctab, no wheezing, rales, or rhonchi. abdomen: soft, obese, nondistended, nontender, +bs extremities: 2+ bilateral le edema with distal dressings in place; r arm edema with pinkness and weaping with demarcation just proximal to the elbow; dressing overlying distal r arm with underyling skin breakdown, r hand cool to touch with pinkness with purple discoloration of distal r arm with clear , dopplers of r radial and ulcer with biphasic pulse; av fistula in l ue without thrill or bruit pertinent results: admission labs: 04:01pm urine color-dkamb appear-cloudy sp -1.018 04:01pm urine blood-lg nitrite-neg protein-100 glucose-tr ketone-tr bilirubin-neg urobilngn-2* ph-5.0 leuk-tr 04:01pm urine rbc-178* wbc-14* bacteria-many yeast-none epi-1 nonsq epi-1 trans epi-1 03:51pm lactate-1.6 03:40pm glucose-295* urea n-150* creat-6.4*# sodium-131* potassium-4.3 chloride-97 total co2-16* anion gap-22* 03:40pm calcium-7.6* phosphate-6.3*# magnesium-2.9* 03:40pm wbc-9.1 rbc-3.01*# hgb-9.2*# hct-28.6*# mcv-95 mch-30.6 mchc-32.2 rdw-17.7* 03:40pm neuts-91.8* lymphs-5.9* monos-2.2 eos-0 basos-0 03:40pm plt count-264 03:40pm pt-23.3* ptt-35.1 inr(pt)-2.2* other pertinent labs: spep- no specific abnormalities seen ppd- negative hepbsag- negative hepbsab- negative hepbcab- negative hepc ab- positive cyclosporine level on discharge 44 (goal <70) microbiology: blood culture- pending, ngtd urine culture- no growth, final mrsa screen- no mrsa isolated urine culture- no growth, final blood culture- pending, ngtd x 2 . studies: - echo: moderate circumferential pericardial effusion no tamponade, lv hypertrophy and small cavity. lvef >55%. there is symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. overall left ventricular ejection fraction is normal (lvef>55%). however, the left ventricular cavity is small, and the stroke volume is likely to be significantly reduced. there is a moderate sized pericardial effusion. - cxr: moderate-to-severe cardiomegaly. - renal u/s: 1. patent main renal artery and vein, but high resistance pattern of flow within the transplanted kidney with absent antegrade diastolic flow throughout the kidney, and absent antegrade diastolic flow in the main renal artery. 2. no evidence of perinephric fluid collection or hydronephrosis. - tte: there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the right ventricular free wall is hypertrophied. the right ventricular cavity is mildly dilated with depressed free wall contractility. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , no change. the morphology and echotexture of the lv and rv are suggestive but not diagnostic for infiltration (i.e. amyloid). if indicated, a cardiac mr with contrast may provide better diagnostic accuracy for myocardial infiltrative processes (vs biopsy). bilateral lenis : no dvt to level of popliteals ue venous mapping : 1. waveform within the right brachial artery as well as low flow within the right radial artery, all suggest impending, if not present, arterial insufficiency to the right upper extremity. 2. occluded left av fistula as indicated by a normal triphasic-appearing left radial artery as well as normal waveforms involving the left subclavian vein. 3. no indirect evidence of central venous occlusion on either the left or right. 4. subcutaneous edema scattered throughout the upper extremities. 5. slow flow within the left radial artery 6. bilateral radial artery calcifications. noninvasive arterial study : 1. occluded ulnar artery. 2. patent brachial and radial arteries to the palmar arch. 3. decreased flow distal to the palmar arch ekg: rbbb. atrial fibrillation. low voltage in the limb leads. . discharge labs: 07:30am blood wbc-11.2* rbc-3.34* hgb-10.0* hct-31.1* mcv-93 mch-30.0 mchc-32.2 rdw-17.1* plt ct-179 07:30am blood pt-16.3* inr(pt)-1.5* 07:30am blood glucose-169* urean-83* creat-4.0* na-136 k-4.5 cl-97 hco3-25 angap-19 07:30am blood calcium-7.5* phos-5.6* mg-2.3 05:50am blood cyclspr-58* brief hospital course: 62 y/o m with esrd s/p lrrt on double immunosuppression with cyclosporine and prednisone, admitted from rehab with acute on chronic renal failure in the setting of several days of hypotension and orthostasis. # acute on chronic renal failure: most likely prerenal vs late rejection vs atn from hypotension. late rejection possible in setting of reportedly decreased dose of cyclosporin before admission and possible decrease in prednisone for steroid myopathy. per renal, most likely represents decreased renal perfusion and ongoing pre-renal azotemia, although duration of hypotension is concerning for perfusion-related injury that has already progressed to atn. consideration for role of rhabdomyolysis given steroid myopathy and generally bedbound state but cks wnl. alternatively, could represent gn or other primary renal process; note made of suspicious degree of iga deposition on allograft biopsy. could also consider contribution from calcineurin inhibitor toxicity or ain from allopurinol or antibiotics that he recently finished though urine eos negative. ulytes mostly c/w prerenal etiology. pt started on hd during admission. urine prot:cr rate 0.9. renal u/s with with absent antegrade diastolic flow and absent antegrade diastolic flow in the main renal artery of unclear significance; no evidence of hydro on u/s. cyclosporin levels were followed daily and were found to be within target range of <70 with 25mg dosing. the patient was started on steroid stress dose and taper. a foley was placed to monitor urine output. pt continued on hd. tunneled line placed by ir. transplant consulted for eval for permanent hd access in setting of l ue av-fistula without thrill or bruit. pt had vein mapping of bilateral ue. pt had neg ppd and hepatitis labs sent in preparation for resuming hd. held off on renal biopsy to assess for late rejection per renal recs. spep/upep negative. # hypotension: etiology not immediately clear, but thought most likely hypovolemia given history of orthostatic hypotension and decreased urine output. unclear what initiated hypotension but possible etiologies included bacteremia from soft tissue infection, obstructive shock from pericardial effusion, restrictive cardiomyopathy, and adrenal insufficiency in setting of chronic prednisone use. am cortisol at rehab was low. pt s/p volume resuscitation in icu (3l ns). pt started on stress dose steroids, which were tapered on the floor back to home dose of 10mg po prednisone daily. bl cx ngtd. ucx negative. in the setting of negative cultures, he was not placed on abx. vip port was placed for hd, and an echocardiogram confirmed hypotension was not due to tamponade. bps improved to 100-120s/30-50s. bps consistently difficult to get accurate measures with cuff on rue. occasional bps in 80s but recheck normalized at times requiring doppler bp measurement to confirm bp. in setting of av fistula in l ue, no bp measurements in left arm for now. ok to perform right ue blood pressures at dialysis, but would otherwise recommend not check bps, or measuring in thighs (as patient has arterial insufficiency in right ue). # arterial insufficiency, r ue: pt noted to have r ue edema distally upon micu callout. edema improved but pinkness and demarcation proximal to the elbow persisted. arterial insufficiency suggested on venous mapping and c/w cool r hand with pink-purplish discoloration. doppler of r radial and ulners pulses present. vascular surgery consulted. pt had noninvasive arterial study, which showed distal flow through the palmar arch, with no urgent need for vascular intervention. patient is scheduled to follow-up with vascular surgery as an outpatient. # pericardial effusion: known pericardial effusion dating back 4 years reportedly. unclear if pericardial effusion had worsened. echo did not show tamponade physiology. likely uremic effusion if worsened from chronic effusion and will likely improve with dialysis. cardiology consulted. # possible restrictive cardiomyopathy: tte with morphology and echotexture of ventricles suggestive but infiltrative process, likely amyloid from hd (beta2-microglobulin). spep/upep negative. cardiology consulted, and recommended no need for cardiac mri or biopsy. # atrial fibrillation: longstanding, on coumadin at home. inr therapeutic. coumadin restarted with home dose 1mg, increased to 2mg for subtherapeutic inrs. # lower extremity venous stasis ulcers: recently (1 week prior to adm) finished a course of antibiotics. no evidence of infection on exam. held off on abx. pt afebrile during stay. wbc uptrended. ulcers did not appears grossly infected but this was only possible source for white count. started pt on 1wk course of cefazolin with 1g on . pt will need 2g on and 2g post-hd on , then course completed. vascular surgery recommended ace wraps to le bilaterally + elevation of legs, in addition to una boots bilaterally. wound care recommendations also included in paperwork. # le edema: r>l on micu callout but became more symmetric. lenis neg for dvt to level of popliteals. # leukocytosis: wbc count uptrended to 12.2--> 12.6 --> 13.7 starting , afebrile. lenis negative per above. culture data ngtd. only localizing source of infection includes le ulcers but without worsening appearance to suggest fevers. # anemia: normocytic, normochromic with iron studies c/w anemia of chronic disease with low iron sat. started fe supplementation in setting of low iron sat. # hyperphosphatemia: hyperphosphatemia likely related to decreased gfr. started phos binder. # hyponatremia: mild, improved. be pseudohyponatremia since it corrects to nearly normal after accounting for hypoglycemia. also be related to atn and decreased ability to excrete free water. # diabetes: continued home nph 26 units qam with sliding scale transitional issues: # tunneled line placed for hd access on discharge. temp hd line pulled . # pt will need f/u with surgery re: fistula for more permanent hd access if renal function does not improve. vein mapping done. pt may benefit from meeting with transplant surgeons for ligation of l av-fistula so that pt could have l ue available for future bp monitoring. # pt will need weekly cyclosporin levels. goal <70. # bps in this patient are very difficult to obtain accurately with a cuff. pt has av fistula in l ue, arterial insufficiency in r ue, and significant le edema. recommend bps in thighs, if not possible, then r ue will be the next best choice. bps running high 80s- to 120s/ 30-50s. if having difficulty getting accurate bp , can check a doppler bp in the r ue if necessary but should otherwise avoid bps in ue bilaterally. bp parameters for concern: sbp <85 and clinical correlation of symptoms # continue wound care of le ulcers. please ace wrap le and elevate legs. una boots bilaterally. # labs for outpatient hd: hep b labs neg, hcv ab positive, ppd neg. # pt discharged off allopurinol, consider restarting in future when renal function more stable. medications on admission: preadmission medications listed are correct and complete. information was obtained from rehab. 1. prednisone 10 mg po daily 2. allopurinol 150 mg po daily 3. calcitriol 0.4 mcg po m, w, f 4. cyclosporine (neoral) modified 25 mg po q12h 5. docusate sodium 100 mg po bid 6. folic acid 1 mg po bid 7. gabapentin 100 mg po every other day 8. hydrocortisone 100 mg po q8h 9. nph 26 units breakfast 10. multivitamins 1 tab po daily 11. nystatin cream 1 appl tp 12. pravastatin 40 mg po daily 13. vitamin d 1000 unit po daily 14. warfarin 1 mg po daily16 15. enalapril maleate 1.25 mg po daily discharge medications: 1. cyclosporine (neoral) modified 25 mg po q12h 2. docusate sodium (liquid) 100 mg po bid hold for loose bms 3. folic acid 1 mg po bid 4. gabapentin 100 mg po every other day 5. nph 26 units breakfast insulin sc sliding scale using hum insulin 6. multivitamins 1 tab po daily 7. pravastatin 40 mg po daily 8. prednisone 10 mg po daily 9. vitamin d 400 unit po daily 10. acetaminophen 325-650 mg po q6h:prn pain 11. calcium acetate 667 mg po tid w/meals 12. collagenase ointment 1 appl tp daily venous ulcers l posterior venous ulcer and 2 r anterior lower leg ulcers 13. ferrous sulfate 325 mg po tid 14. miconazole powder 2% 1 appl tp tid:prn fungal infection 15. senna 1 tab po bid:prn constipation 16. cefazolin 2 g iv post hd duration: 1 doses on 17. warfarin 2 mg po daily16 18. cefazolin 2 g iv once duration: 1 doses on discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: hypovolemic hypotension acute on chronic renal failure lower extremity venous stasis ulcers secondary diagnosis: s/p kidney transplant discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear mr. , it was a pleasure taking care of you in the hospital. you were admitted with low blood pressures requiring a stay in the icu. you were given iv fluids and steroids to help your blood pressure. your cultures did not show signs of infection. your blood pressures improved. your kidney function worsened during your hospitalization and you had to restart on dialysis. you had a tunneled line placed so that you may continue dialysis at rehab; but the doctors there continue to watch you closely for return of your renal function. please follow-up at the appointments listed below. please see the attached list for changes to your outpatient medications. followup instructions: please follow-up with the doctor at your extended care facility. department: transplant center when: wednesday at 9:00 am with: , md building: lm campus: west best parking: garage department: transplant center when: thursday at 1:15 pm with: , md building: lm bldg () campus: west best parking: garage we are working on a follow up appointment for your hospitalization in vascular surgery with dr. . you need to be seen within 1 week of discharge. the office will contact you with an appointment. if you have not heard within 2 business days please call the office at . md procedure: hemodialysis venous catheterization for renal dialysis diagnoses: acidosis anemia in chronic kidney disease nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere long-term (current) use of steroids adrenal cortical steroids causing adverse effects in therapeutic use acute kidney failure, unspecified hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes chronic kidney disease, unspecified unspecified disease of pericardium disorders of phosphorus metabolism long-term (current) use of insulin morbid obesity long-term (current) use of anticoagulants personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits toxic myopathy diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled other specified hypotension kidney replaced by transplant venous (peripheral) insufficiency, unspecified ulcer of lower limb, unspecified osteoarthrosis, localized, not specified whether primary or secondary, lower leg body mass index 37.0-37.9, adult 

Answer: The patient is high likely exposed to