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: naproxen attending: chief complaint: urosepsis; metabolic acidosis major surgical or invasive procedure: endotracheal intubation placement of picc placement of tunneled catheter for hemodialysis removal of tunneled catheter history of present illness: 76 y/o f with dm, htn, pvd, afib not on coumadin due to hx of sdh, cri who was taken to hosp today for worsening mental status. +n/v x3 days, + diarrhea on questioning. initial vs at scene nml. here denies any cp, sob, dyspnea, orthopnea. denies any abd pain, cp, ha, visual changes. not able to relate any further hx. denies any new meds, but does not have accurate history of her meds. . on transfer to our ed, her vs were 97.9, hr 93, bp 143/63, rr 22, 94% on 4l nc. her rr increased progressively to the 30s, and she was placed on a nrb for hypoxia. she was given 2 amps bicarb, 1gram of tylenol and admitted to the micu in the setting of her profound acidosis. past medical history: 1. dm ii with neuropathy 2. pvd 3. hypertension 4. dyslipidemia 5. atrial fibrillation 6. h/o tuberculosis s/p lul resection 7. h/o diverticulosis s/p bowel resection 8. osteoarthritis 9. h/o arrythmia s/p av node ablation . s/p tah, s/p c-section 11. s/p spinal surgery . s/p rt. hip surgery . s/p rt. eia endartectomy with patch angioplasty w dacron 14. s/p b/l foot surgeries 15. sdh s/p mechanical fall 16. suspected diastolic dysfunction 17. cri likely due to htn/dm; baseline 1.6-1.8 18. copd on home oxygen (no pfts in omr) social history: married and lives with spouse of 26 years; has 2 kids. reports smoking (quit 20 years ago), admits to drinking glasses of wine with dinner daily. family history: non-contributory physical exam: admission exam: vs: temp:97.1 bp:111/53 hr:75 rr:16 o2sat: 97% 2l nc gen: pleasant, comfortable, nad heent: perrl, eomi, anicteric, mmm, op without lesions neck: no jvd resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl. iv/vi systolic murmur at rusb that radiates to carotids abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: +le chronic ulcers with some granulation tissue; some areas of pus formation. +charcot joints bilaterally. wrist joints with arthritis. neuro: aaox2. moves all ext spont. discharge exam: neuro: lue 4/5 strength at proximal and distal muscles, strength at rue, 1-2/5 strength in lle, 3/5 strength in rle. pertinent results: labs on admission: 05:01pm blood wbc-11.3* rbc-3.46* hgb-9.8* hct-31.7* mcv-92 mch-28.3 mchc-30.9* rdw-18.0* plt ct-115*# 05:01pm blood neuts-85.8* lymphs-5.2* monos-3.7 eos-5.2* baso-0.1 05:01pm blood pt-13.8* ptt-42.1* inr(pt)-1.2* 05:01pm blood glucose-84 urean-86* creat-6.4*# na-143 k-3.7 cl-115* hco3-7* angap-25* 05:30pm blood alt-8 ast-15 ld(ldh)-368* ck(cpk)-363* alkphos-103 totbili-0.7 05:30pm blood ck-mb-12* mb indx-3.3 ctropnt-0.15* 10:59pm blood ck-mb-11* mb indx-3.7 ctropnt-0.15* 05:44am blood ck-mb-10 mb indx-4.5 ctropnt-0.16* 05:01pm blood albumin-3.2* calcium-7.7* phos-9.2*# mg-1.8 05:13am blood caltibc-156* ferritn-721* trf-120* 05:01pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg . labs on discharge: : na: 142 k: 4.8 cl: 113 co2: 18 bun: 53 cr: 2.4 glu: 78 ca: 8.8 mg: 2.2 p: 5.0 : wbc: 6.1 hct: 33.8 plt: 147 : pt: 14.8 ptt: 53.1 inr: 1.3 . ct head without contrast : impression: no acute intracranial pathology. please note that mri is more sensitive for the detection of early cva. if clinically indicated, mri with diffusion images could be performed. . ct abdomen/pelvis : impression: 1. large left retroperitoneal hematoma involving the iliopsoas extends down into the left groin. 2. unchanged nodular enlargement of the left adrenal gland is incompletely characterized on this non-contrast ct. 3. interstitial thickening of the dependent lung bases suggest volume overload. . portable abdomen :impression: right-sided 7 mm renal stone located overlying the right transverse process of the l4 vertebral body corresponding closely to the right renal stone identified in the ct. . mri brain/head/neck : findings: brain mri: there are several areas of slow diffusion identified in both cerebral hemispheres. in the right cerebral hemisphere, prominent approximately 1-cm area of slow diffusion seen in the right basal ganglia periventricular region. in addition, several small subcortical areas of hyperintensity seen, one in the right periatrial region and the second in right parietal subcortical region. in addition, small areas of slow diffusion are seen in the left basal ganglia periventricular region and left parietal subcortical region. findings are indicative of multiple acute infarct, probably from embolic source. there is no midline shift, mass effect or hydrocephalus. moderate brain atrophy and mild-to-moderate changes of small vessel disease are identified. the suprasellar and craniocervical regions are normal. . impression: multiple small acute infarcts in the subcortical region as described above. moderate brain atrophy and mild changes of small vessel disease. . mra of the neck: neck mra somewhat limited by motion demonstrates mild atherosclerotic disease at both internal carotid origin. no evidence of high-grade stenosis seen in the internal carotid carotids. stenosis is also seen at the origin of the right external carotid. both vertebral arteries demonstrate tortuosity, which could be secondary to cervical spondylosis. . impression: mild atherosclerotic at the origin of both internal carotid arteries. the evaluation is somewhat limited by motion. . mra of the head: the head mra demonstrates normal flow signal in the arteries of anterior and posterior circulation. both middle cerebral artery bifurcation regions are not visualized on projection images. in addition, both posterior cerebral arteries are not well visualized on projection images. however, these vessels are well visualized on the source images. impression: no significant abnormalities on mra of the head. . bilateral duplex le : impression: no evidence of dvt involving the right or left lower extremities. . ct head : impression: evidemce of sinusitis invloving bilateral sphenoid, left ethmoid sinuses. opacification of right mastoid air cells. no acute intracranial pathology, hemorrhage or masses. . echo : the left atrium is dilated. the right atrium is moderately dilated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is severe aortic valve stenosis (area <0.8cm2). the left ventricular inflow pattern suggests impaired relaxation. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , the ejection fraction now appears normal. moderate symmetric lvh, severe as and moderate pulmonary artery systolic hypertension are similar to prior. . ct without contrast : impression: 1. severe upper lobe predominant interstitial and ground-glass opacities, with a small simple right pleural effusion and scattered pathologically enlarged mediastinal lymph nodes. differential considerations include hemorrhage, interstitial pneumonia (either infectious or acute, idiopathic) and noncardiac edema. 2. probable calcific aortic stenosis. severe coronary, aortic and branch atherosclerosis. 3. nodular enlargement of the left adrenal gland, which cannot be further characterized on this study. if clinically indicated, an mri or adrenal protocol ct may be considered. 4. subcentimeter splenic hypodensity, which is also incompletely characterized. 5. nasogastric tube terminating in the distal esophagus. . renal u/s : no hydronephrosis . cxr : upright ap and lateral views of the chest are obtained. there is persistent cardiomegaly. improved aeration at the left lung base is noted. mild interstitial prominence is again noted, which may represent interstitial edema. mediastinal contour is unremarkable. atherosclerotic calcification of the aortic knob is again noted. no large effusions are present. visualized osseous structures are intact. clips are noted in the left upper quadrant. brief hospital course: 76 y/o f with dm, htn, pvd, afib, hx of sdh, cri who was taken to hosp for worsening mental status found to be in arf with severe acidosis. transferred to micu for management. hosp course by problem: . # acute respiratory distress: she initially was tachypneic to compensate for her metabolic acidosis. she then developed hypoxia and increased work of breathing. she was intubated for hypoxic respiratory failure. ct chest without contrast showed bilat infiltrates. initially, concerning for infectious vs chf vs interstitial lung disease. she was started on vanco, ceftriaxone (also for uti), and azithro to cover broadly for infectious causes. she briefly was treated with steroids given possibility of interstitial pneumonitis however bronch only showed 1 eosinophil thus this was stopped. she then was aggressively diuresed and improved dramatically. thus, much of her distress was thought secondary to fluid overload given 1) aggressive ivf resusc in osh and 2) likely chf. however, her sputum grew gnr and ceftriaxone was switched to zosyn and vanc was started on for vap. pt was also diuresed with lasix gtt and iv lasix for pulmonary edema. vanc was stopped after 8 days as sputum only grew pseudomonas. zosyn was switched to cefepime on when gnr was identified as pseudomonas (later, sensitivities returned sensitive to zosyn and cefepime/). pt was extubated on and did well. pt is to have 14 day course of abx for pseudomonas and last day of cefepime is . pt continued to diurese intermittently with iv lasix which was switched to po lasix to keep her i/o even. lasix was temporarily discontinued when the patient began dialysis, but she was restarted on lasix when dialysis was stopped. her oxygen saturations remained in the mid-90s on room air. . # severe acidosis and acute on chronic renal failure: acute onset not entirely clear. she had had poor po intake, n/v for several days prior to admit. her cr though increased dramatically from baseline. she also had ph of 7.03 on presentation. delta-delta suggested ag (renal failure) and nonag (? ivf) acidosis. she received hco3 in ed and gradually stabilized. her creatinine peaked at 6.8 and trended down once she diuresed. acidosis resolved as creatinine improved. the patient had a tunnelled catheter placed for hemodialysis by interventional radiology and hemodialysis was started for uremia. she was followed by the renal service, and the decision was made to stop dialysis, given a return of her creatinine to a new baseline of 2.5. her hemodialysis catheter was removed on without incident. following discontinuation of her hemodialysis, she was started on renagel 1600 tid, and sodium bicarb 600 mg tid. she has an appointment scheduled with dr. on at 10:00 am. her creatinine remained stable off dialysis. . # atrial fibrillation: pt was in sinus at admission and while intubated. however, post-extubation, pt went into atrial fibrillation with rapid ventricular response to 140-150s. pt was continued on home dose amiodarone which was intermittently held for ?pulmonary fibrosis and a couple of bradycardia episodes but was started when af with rvr occurred. pt initially responded to iv/po metoprolol, but later there wasn't a good rate response. thus, diltiazem drip and po dilt was started with hr in 90-100s. ep was consulted and recommended increasing amiodarone to 400mg and switching to metoprolol. pt was not anticoagulated at home and anticoagulation was not continued until she suffered a stroke (see below for details) and then anticoagulation was started.her amiodarone was decreased back to 400 mg qd and her diltiazem was titrated up to 60 mg qid. her heart rate was better controlled on this regimen in the 60s-80s, with occasional return to sinus rhythm; however, she continued to have bursts up to the 120s. anticoagulation is discussed below regarding her retroperitoneal bleed. her amiodarone will have to be reduced to 200 mg qd in 1 week. . # embolic stroke: on , pt was noted to have l sided weakness with l facial droop. stat head ct was obtained and neuro was consulted. ct did not reveal acute processes, but mri later recommended by neuro whose suspicious was high for r mca stroke showed r caudate stroke. pt was started on argatroban initially as there was a concern for hit as plts were trending down and with new stroke in the setting of nsr. hit came back negative, and argatroban was switched to heparin and plts continued to rise. patient's strength continued to improve during her hospital stay. neuro exam on discharge revealed 4/5 strength in the lue, 5/5 strength in the rue, 2/5 strength in lle, strength in rle. . #. retroperitoneal bleed: patient had acute rp bleed, with a hct drop of 15 points, while on heparin gtt for acute embolic stroke during her course in the icu. since rp bleed, the patient had been off of anticoagulation. she was monitored closely for back and flank pain, and her hematocrit was monitored closely, without subsequent drops. heparin gtt was restarted on , with a goal ptt of 40-60, until patient proved stable (had retroperitoneal bleed as below) her ptt goal was then increased to 60-80. she was started on coumadin 2.5 on . her inr on day of discharge was 1.3, and she will need to continue on the heparin gtt until her inr is therapeutic. she will need inr levels closely monitored. she will need to be monitored for back/flank pain and hematocrit drop to watch for recurrence of her rp bleed. also, patient has been transiently guaiac positive with brown stools, now resolved. also, anemia due to chronic renal insufficiency treated with procrit. . # thrombocytopenia: likely due to marrow suppression in setting of arf and uti. when pt suffered a stroke, hit was sent and argatroban was started. later, hit came back negative. her platelets were closely monitored. . # cards chf: echo showed no diastolic or systolic function. however, she was thought profoundly fluid overloaded. she responded to diurel and lasix 80 then was placed on lasix gtt for 1 day. good uop then auto-diuresed well. the patient was restarted on lasix 40 qd after her hemodialysis was discontinued. . # cards vessels: trop leak thought demand ischemia. no new wall motion abnl. pt was started on lipitor when stroke was found. the patient wsa maintained on telemetry, and denied chest pain. . # uti: to ceftriaxone. received 7 d course. yeast was found in her urine and she completed a 14 day course of fluconazole. . # le ulcers: the patient has bilateral lower extremity ulcers on her feet. unclear etiology; per old notes has ? hx of paraproteinuria vs diabetic neuropathy, wound care was consulted, and dressed her ulcers. podiatry also came to see her ulcer, and indicated that no new acute surgery was necessary. nutrition was encouraged to promote wound healing. she will need qod dressing changes on her feet, and her ulcers should be considered if she an increase in her temperature. . #. urinary yeast infection: many yeast on ua. ucx no growth. fluconazole was completed with a 14 day course. . #. s/p pseudomonas pneumonia: patient afebrile, leukocytosis resolving, good sat on room air, no dyspnea. s/p 2 week course of cefepime. follow up chest x-ray shows pulmonary vascular congestion without obvious infiltrate. . #. dm: her diabetes mellitus was managed with a sliding scale insulin regimen with fingersticks 4 times daily. . #. hypernatremia: the patient was found to be hypernatremic and fluid boluses were initiated. with the start of hemodialysis, hypernatremia resolved and fluid boluses were stopped; however, when hemodialysis was discontinued, fluid was gently restarted. . fen: tf started . when it was felt that the patient could take adequate po, tube feeds were stopped andd she was seen by the speech and swallow team. her diet was slowly advanced to thin liquids and soft foods. pt's intake towards the end of her hospital course was improved, however not entirely adequate. she refused an ng tube or peg tube. . access: picc . prophylaxis: the patient was started on subcutaneous heparin for prophylaxis initially, then, heparin gtt was started when it was felt that her retroperitoneal bleed was stable. she was started on a proton pump inhibitor for ulcer prophylaxis. . code: full code confirmed on multiple occasions during the hospital stay. medications on admission: amio 200 qd calcitriol 0.25 zoloft 100 senna synthroid 25mcg zyprexa 2.5 qd folic acid/thiamine/mvi ambien qhs percocet prn toprol xl 50 norvasc 5 ppi 40 humalog ss coumadin 5 lasix 20 qod . allergies: naproxen --> renal toxicity discharge medications: 1. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. tablet(s) 2. insulin lispro 100 unit/ml solution : one (1) insulin per sliding scale subcutaneous asdir (as directed). 3. sertraline 50 mg tablet : two (2) tablet po daily (daily). 4. levothyroxine 25 mcg tablet : one (1) tablet po daily (daily). 5. folic acid 1 mg tablet : one (1) tablet po daily (daily). 6. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 7. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed. 8. fluticasone 110 mcg/actuation aerosol : four (4) puff inhalation (2 times a day). 9. hexavitamin tablet : one (1) cap po daily (daily). 10. atorvastatin 40 mg tablet : two (2) tablet po daily (daily). 11. miconazole nitrate 2 % cream : one (1) appl topical (2 times a day). 12. ipratropium bromide 0.02 % solution : one (1) nebulizer inhalation inhalation q6h (every 6 hours) as needed. 13. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed. 14. olanzapine 5 mg tablet : 0.5 tablet po daily (daily). 15. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 16. sevelamer 800 mg tablet : two (2) tablet po tid w/meals (3 times a day with meals). 17. metoprolol tartrate 50 mg tablet : two (2) tablet po qid (4 times a day): hold for sbp <90 or hr <55. 18. amiodarone 200 mg tablet : two (2) tablet po daily (daily). 19. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 20. diltiazem hcl 60 mg tablet : one (1) tablet po qid (4 times a day): hold for sbp <100 . 21. zolpidem 5 mg tablet : one (1) tablet po hs (at bedtime) as needed for insomnia. 22. epoetin alfa 4,000 unit/ml solution : one (1) injection 4000 units/ml injection qmowefr (monday -wednesday-friday). 23. furosemide 40 mg tablet : one (1) tablet po daily (daily). 24. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 25. sodium bicarbonate 650 mg tablet : two (2) tablet po bid (2 times a day). 26. calcium acetate 667 mg capsule : one (1) capsule po tid w/meals (3 times a day with meals). 27. warfarin 2.5 mg tablet : one (1) tablet po daily (daily). 28. heparin (porcine) in d5w 100 unit/ml parenteral solution : one (1) sliding scale asdir intravenous asdir (as directed): until inr therapeutic. please titrate ptt to target 60-80. 29. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: hospital of & islands discharge diagnosis: primary diagnoses: ventilator associated pneumonia acute on chronic renal failure metabolic acidosis atrial fibrillation with rapid ventricular response valvular and acute diastolic heart failure cardioembolic right basal ganglia stroke - left hemiparesis. retroperitoneal bleed blood loss anemia anemia of chronic kidney disease uti rectal bleeding secondary diagnoses: chronic kidney disease stage iv copd on home oxygen diabetes mellitus type ii hypertension hypercholesterolemia atrial fibrillation sdh s/p mechanical fall mod/severe aortic stenosis osteoarthritis av node ablation s/p tah, s/p c-section s/p spinal surgery s/p right hip surgery s/p b/l foot surgeries h/o tuberculosis s/p lul resection h/o diverticulosis s/p bowel resection right cfa below-knee popliteal artery bypass graft endarterectomy of right internal iliac artery and dacron patch severe peripheral neuropathy and pvd s/p bilateral foot reconstruction discharge condition: fair discharge instructions: you were admitted to the hospital and had a long hospital stay. you were initially placed in the icu. you had a stroke, and blood thinners were started initially, but after developing a bleed, the blood thinners wre temporarily stopped. they were restarted when it was felt that it was stable. you also had a pneumonia and you were given antibiotics. furthermore, your kidneys had failure, and you were followed by the renal team and started on hemodialysis, which was discontinued when your renal function remained stable. your medications were monitored carefully and you will need assistance with your medications. you will remain on the heparin drip until you are appropriately anticoagulated. then, you will only have to take warfarin (coumadin) for anticoagulation. . you should call your primary care doctor, or return to the emergency room with any new symptoms of chest pain, shortness of breath, fever >101.4 f, any new weakness, or any other symptoms which are concerning to yuo. followup instructions: you have an appointment with dr. (renal). provider: , md phone: date/time: 10:00. please call if you are unable to keep this appointment. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis closed [endoscopic] biopsy of bronchus incision with removal of foreign body or device from skin and subcutaneous tissue transfusion of packed cells transfusion of other serum diagnoses: acidosis anemia in chronic kidney disease pure hypercholesterolemia congestive heart failure, unspecified acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) severe sepsis candidiasis of other urogenital sites chronic airway obstruction, not elsewhere classified chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation aortic valve disorders other chronic pulmonary heart diseases diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes personal history of tobacco use occlusion and stenosis of carotid artery without mention of cerebral infarction ulcer of other part of foot acute respiratory failure pneumonia due to pseudomonas other specified septicemias other generalized ischemic cerebrovascular disease long-term (current) use of anticoagulants pressure ulcer, lower back cerebral embolism with cerebral infarction acute diastolic heart failure occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled hemiplegia, unspecified, affecting unspecified side hemorrhage, unspecified ulcer of other part of lower limb unspecified sinusitis (chronic) hemorrhage of rectum and anus arthropathy associated with neurological disorders urinary calculus, unspecified 

Answer: The patient is high likely exposed to