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: ambien attending: chief complaint: acute renal failure major surgical or invasive procedure: angiography of lower limbs history of present illness: mr. is a 79 year old male with past medical history of congestive heart failure, coronary artery disease, copd, and diabetes mellitus who was transferred to for further management after being found to have hyperkalemia, worsening renal function, and hypotension. . he presented to today after being referred there when routine laboratory draw revealed abnormalities. his potassium was found to be 6.1, and creatinine 4.7. blood pressure there was noted to be 83/42. he was given an albuterol nebulizer, 1 amp of calcium gluconate, 10 units of regular insulin, 1 amp of d50, and 30 mg of kayexalate, as well as 500 cc of normal saline. . in the ed here at , initial vital signs were: blood pressure of 91/54, heart rate of 76, respiratory rate of 22, and oxygen saturation of 90%. a right femoral central line was placed for initiation of pressors, and he was started on neo. he was given 1 gram of vancomycin and 4.5 grams of zosyn for possible urinary tract infection. he received 1 gram of calcium gluconate, 1 amp of d5, and 10 units of regular insulin as well for hyperkalemia. renal and cardiology were consulted. . on the floor, he reports he has to move his bowels, but otherwise denies any shortness of breath or other complaints. of note, has highly variable bp readings depending on position, alternating in rapid sequence from 70-110's systolic. . of note, he was recently admitted to cardiology service from until after being transferred from . at that time, he had acute on chronic renal insufficiency, as well as hypotension. he was diuresed with a lasix drip, which was switched to torsemide. ep also followed the patient, and his icd was re-programmed to allow for native conduction, with consideration of up-grade to -ventricular pacer in future, as this was deferred given improvement in his symptoms with diuresis. his blood pressure was noted to be 70-100 systolic during that admission with normal mentation. elevated creatinine was felt to be secondary to poor forward flow, and lft elevations secondary to congestion. . he states that since his admission, he has been at rehabilitation. he reports he gained about 10 pounds since discharge, though he's not sure how. on he presented to for hyperkalemia, worsening renal function, and hypotension. past medical history: 1. cardiac risk factors: -coronary artery disease (s/p mi x2) -diabetes (type 2 insulin-dependant) -dyslipidemia -hypertension 2. cardiac history: -cabg: -s/p cabg in (lima->diag, svg->om1, svg->lad) -percutaneous coronary interventions: -s/p prior lad stent and ptca of diag -s/p to rca in -ppm/icd: - ischemic cardiomyopathy, s/p icd implantation - ppm (unclear when placed) -other cardiac history: - paroxysmal atrial fibrillation - nonsustained ventricular tachycardia - chronic systolic chf ischemic cardiomyopathy(last ef 20%) - mitral regurgitation - pulmonary hypertension 3. other past medical history: -chronic obstructive pulmonary disease on 3l home o2 since -chronic renal insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -severe peripheral vascular disease, s/p left fem- bypass -obstructive sleep apnea intolerant to cpap -gerd -anxiety -depression -post traumatic stress disorder social history: married and lives with his wife. retired from army. most recently worked as a cook at the . he used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. family history: father died of an mi at age 48. brother died of an mi at age 64. physical exam: afebrile, bp 116/53, hr 91, rr 28, oxygen saturation 98% on 3l general: male resting in bed, intermittently trying to sit up, then asleep, appearing mildly distressed heent: nc/at, perrl, eomi, slightly dry mm neck: supple, jvp elevated to ear lungs: decreased bs over bases, right > left, no wheezes or rales cardiac: irregularly irregular, though regular at times abd: soft, nt, nd, +bs extr: pitting edema bilaterally, improved from prior, eschar over right heel and right lateral foot below metatarsal. skin: fragile skin tears neuro: awake, though unable to assess if oriented to place--oriented to self, speech slightly dysarthritic at times, poor attention able to follow some commands. occasional myoclonic shaking when awakening. psych: agitated. pertinent results: admission labs: 03:30pm blood wbc-10.4 rbc-4.28* hgb-13.0* hct-40.8 mcv-95 mch-30.3 mchc-31.7 rdw-17.2* plt ct-244 03:30pm blood neuts-79.3* lymphs-9.6* monos-9.4 eos-1.2 baso-0.5 05:18pm blood pt-25.7* ptt-33.0 inr(pt)-2.5* 03:30pm blood glucose-204* urean-77* creat-4.4*# na-130* k-5.9* cl-92* hco3-21* angap-23* 09:00pm blood alt-120* ast-250* ld(ldh)-353* ck(cpk)-127 alkphos-58 totbili-1.1 09:00pm blood albumin-3.6 calcium-8.6 phos-7.0*# mg-2.8* cardiac biomarkers: 03:30pm blood ctropnt-0.07* 09:00pm blood ck-mb-9 ctropnt-0.08* 04:12am blood ck-mb-8 ctropnt-0.09* 03:14am blood ck-mb-4 ctropnt-0.05* 03:30pm blood probnp-7763* u/a 03:48pm urine color-amber appear-hazy sp -1.016 03:48pm urine blood-lg nitrite-neg protein-75 glucose-neg ketone-tr bilirub-sm urobiln-4* ph-6.5 leuks-sm 03:48pm urine rbc-* wbc-21-50* bacteri-mod yeast-none epi-0 03:48pm urine castgr-0-2 casthy-* bcx negati x 2 recent labs prior to discharge: 02:16pm blood wbc-8.9 rbc-4.37* hgb-12.9* hct-39.1* mcv-90 mch-29.5 mchc-32.9 rdw-16.1* plt ct-263 06:14am blood wbc-9.6 rbc-4.37* hgb-12.4* hct-38.4* mcv-88 mch-28.5 mchc-32.4 rdw-16.3* plt ct-264 05:48am blood wbc-10.1 rbc-4.30* hgb-12.5* hct-37.8* mcv-88 mch-29.0 mchc-33.0 rdw-16.1* plt ct-246 09:21am blood wbc-9.5 rbc-4.53* hgb-12.8* hct-39.5* mcv-87 mch-28.3 mchc-32.4 rdw-16.3* plt ct-263 02:43pm blood wbc-9.5 rbc-4.56* hgb-13.3* hct-40.0 mcv-88 mch-29.1 mchc-33.2 rdw-16.0* plt ct-231 05:43am blood wbc-10.2 rbc-4.48* hgb-13.2* hct-39.5* mcv-88 mch-29.3 mchc-33.3 rdw-16.2* plt ct-242 03:14am blood neuts-74.0* lymphs-13.7* monos-10.1 eos-1.9 baso-0.3 05:48am blood neuts-77.3* lymphs-11.0* monos-9.4 eos-1.7 baso-0.7 09:21am blood pt-26.5* ptt-33.6 inr(pt)-2.6* 09:21am blood plt ct-263 02:43pm blood pt-25.3* ptt-31.0 inr(pt)-2.4* 02:43pm blood plt ct-231 05:43am blood pt-27.3* ptt-31.4 inr(pt)-2.7* 05:43am blood plt ct-242 02:34pm blood glucose-196* urean-36* creat-1.7* na-136 k-4.3 cl-97 hco3-29 angap-14 05:52am blood glucose-101* urean-35* creat-1.7* na-137 k-3.9 cl-98 hco3-31 angap-12 02:58pm blood glucose-246* urean-35* creat-1.7* na-137 k-4.0 cl-97 hco3-29 angap-15 02:45am blood glucose-142* urean-34* creat-1.8* na-138 k-3.7 cl-98 hco3-32 angap-12 02:16pm blood glucose-171* urean-32* creat-1.6* na-135 k-4.7 cl-96 hco3-33* angap-11 06:14am blood glucose-150* urean-31* creat-1.8* na-136 k-3.8 cl-94* hco3-34* angap-12 05:48am blood glucose-103* urean-29* creat-1.9* na-137 k-4.0 cl-93* hco3-33* angap-15 02:44pm blood glucose-250* urean-33* creat-1.9* na-134 k-3.6 cl-90* hco3-34* angap-14 09:21am blood glucose-164* urean-30* creat-1.8* na-135 k-3.9 cl-89* hco3-37* angap-13 02:43pm blood glucose-195* urean-30* creat-1.9* na-132* k-3.3 cl-86* hco3-37* angap-12 05:43am blood glucose-198* urean-32* creat-1.9* na-136 k-2.9* cl-86* hco3-38* angap-15 06:14am blood alt-22 ast-23 alkphos-46 totbili-1.2 03:14am blood ck-mb-4 ctropnt-0.05* 05:43am blood calcium-9.2 phos-3.0 mg-1.9 art dup ext lo uni;f/u left preliminary report only. chest xray : impression: ap chest compared to . lateral aspect right lower chest is excluded from the examination. new hazy opacification at the right lung base could be due to either recent aspiration or developing asymmetric edema. moderate cardiomegaly and mediastinal vascular engorgement have both increased. small left pleural effusion is unchanged. right picc line ends in the svc and a transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements, unchanged. no pneumothorax. cardiology report ecg study date of 12:19:20 am atrial paced rhythm with intrinsic a-v conduction, frequent ventricular ectopy and fusion beat. compared to the previous tracing of there is frequent ventricular ectopy. otherwise, no diagnostic interim change. intervals axes rate pr qrs qt/qtc p qrs t 80 0 132 418/453 0 -29 139 urine culture (final ): staphylococcus, coagulase negative. 10,000-100,000 organisms/ml.. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. staphylococcus, coagulase negative. 10,000-100,000 organisms/ml.. second morphology. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | gentamicin------------ 8 i <=0.5 s levofloxacin---------- =>8 r =>8 r nitrofurantoin-------- <=16 s <=16 s oxacillin------------- =>4 r <=0.25 s tetracycline---------- =>16 r 2 s vancomycin------------ 2 s 1 s brief hospital course: he was transferred to ed where he was triaged as septic, given neosynephrine, vancomycin, zosyn, and treated for hyperkalemia. . in micu, he was diuresed on lasix drip and noted to have baseline sbps 70s-80s in acute on chronic systolic congestive heart failure with ef 20%. with diuresis he was able to maintain sbps off pressors in 80s and his renal function improved. his infectious work-up was negative. he was transferred to cardiology floor on a lasix drip for diuresis. overnight , he was reported to be agitated and intermittently hypoxic to 80s after which he would awaken and be startled. he was transferred to the micu for higher level of nursing care. assessment there suggested multiple factors including adverse reaction to sleep aide (ambien), high dose ciprofloxacin (for empiric uti treatment), haldol and hypoxia in setting of known sleep apnea not on bipap. with observation and cessation of medications the patient's mental status improved to baseline and he was no longer hypoxic. ambien was felt to be the primary cause and should not be given again; avoid in the future. . he was seen by vascular surgery and podiatry for his severe peripheral vascular disease and chronic ulcers. no current inpatient managment was felt necessary at that time given chf exacerbation. however, during agressive diuresis of the patient, mr. developed cellulitis of his right lower limb. due to the edema and poor blood supply to the legs given his vascular disease, the pt developed an infection of the skin and healing ulcers on his feet. he was given broad spectrum iv antibiotics to treat the infection (vancomycin, cipro and flagyl x7days). . in addition, given the development of infection, vascular surgery performed an angiography in an attempt to improve blood flow to in order to facility abx treatment. the legs showed significant blockages which require correction; however, vascular surgery was not able to perform any stenting due to patient movement. thus, vascular surgery arranged to use general anesthesia for the procudure balloon or stenting of the leg blood vessels; tentatively vascular surgery will perform this on . . although there was as strong preference by all care providers involved that the patient remain at while completing iv antibiotics and awaiting surgery, the patient was adament that he be moved closer to home to to complete iv antibiotics until the time of the vascular intervention. arrangements were made and the pt was transferred to . . please note that ambien has been added to pt's list of allergies. medications on admission: - albuterol nebulizer q2 hours prn - amiodarone 100 mg daily - ascorbic acid 500 mg daily - aspirin 325 mg - fenofibrate 145 mg qhs - fluticasone/salmeterol 250/50 - laisx daily--? dose - humalog mix 50/50 - levothyroxine 25 mcg - metoprolol succinate 25 mg + 50 mg daily - multiple vitamin - polyethylene glycol daily - ranitidine 150 mg daily - senna - simvastatin 10 mg - bactrim ds - tramadol 50 mg q8h - trazodone 50 mg qhs - valsartan 40 mg daily - velafaxine er 75 mg qhs ** of note, discharge summary from as the following medications listed differently: - venlafaxine 75 mg--1.5 tablets daily - torsemide 100 mg daily - metoprolol succinate 50 mg daily - warfarin discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for wheeze, shortness of breath. 3. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 4. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 6. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. tramadol 50 mg tablet sig: one (1) tablet po every eight (8) hours as needed for pain. 9. amiodarone 200 mg tablet sig: 0.5 tablet po daily (daily). 10. simvastatin 10 mg tablet sig: one (1) tablet po hs (at bedtime). 11. valsartan 40 mg tablet sig: one (1) tablet po daily (daily). 12. venlafaxine 75 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 13. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 14. multivitamin tablet sig: one (1) tablet po once a day. 15. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 16. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 4 days: pt should complete 7 day course to end on . 17. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 18. insulin lispro 100 unit/ml cartridge sig: one (1) unit subcutaneous asdir: see attached sheet. 19. insulin nph & regular human 100 unit/ml (70-30) cartridge sig: six (6) unit subcutaneous asdir: see attached sheet. 20. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 21. docusate sodium 100 mg capsule sig: one (1) capsule po daily (daily). 22. warfarin 1 mg tablet sig: three (3) tablet po daily (daily). 23. metolazone 5 mg tablet sig: one (1) tablet po daily (daily). 24. multivitamin tablet sig: one (1) tablet po daily (daily). 25. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 26. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). 27. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours). 28. furosemide 80 mg tablet sig: two (2) tablet po bid (2 times a day). 29. dextrose 50% in water (d50w) syringe sig: one (1) intravenous prn (as needed) as needed for hypoglycemia protocol. 30. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary diagnosis: congestive heart failure acute renal failure secondary diagnosis: hyperkalemia (high potassium, electrolyte imbalance) coronary artery disease copd diabetes mellitus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you came to the hospital because you had gained 10 pounds and were experiencing with difficult breathing and substantially increased swelling of you lower legs. you were found to have dnagerous electrolyte imbalances, worsening kidney function and very low blood pressure. this was an exacerbation of your chronic heart failure and there was concern for infection. . while in the hospital, your symptoms worsened and you were transferred to the icu and received antibiotics. although there was concern for infection, tests were negative. after further investigation it was felt that ambien (a medication you received) caused significant unexpected adverse side effects in you. we recommend that you never take ambien again and have listed it as a medication in your record. please be sure to alert you pcp and other doctors of this . . to treat your heart failure you received medications to remove excess fluid that had accumlated in your body. with the removal of this fluid your symptoms improved. however, due to the edema and poor blood supply to your legs due to vascular disease, you developed an infection of the skin and healing ulcers on your feet. you were given iv antibiotics to treat this infection. you responded well but require continued treatment of the infection with iv antibiotics. . in addition, vascular surgery performed an angiography and other tests of you blood vessels in you legs which showed significant blockages which require correction; if these are not corrected you risk continued life threatening infections of the legs and ampulation. correction of these blockages was attempted while you were here but was not success in the setting of only partial sedation during the procedure. thus, vascular surgery will be arranging to use general anesthesia (complete sedation) for the procudure to open the leg blood vessels; you have an appointment with vascular surgery on to further address this issue. . given your strong preference to be closer to your family, you were transferred to an outside care facility () once you stablized in order to continue the removal of the remaining fluid you had accumulated and the complete your course of iv antibiotics for the treatment for your infection. . the following changes were made you your medications: - please continue taking furosemide 160mg po twice daily. - please continue taking metolazone 5mg daily. - please continue taking vancomycin 1000 mg iv q 24h - please continue taking metronidazole (flagyl) 500 mg po/ng q8h - please continue taking ciprofloxacin hcl 500 mg po/ng q12h - please continue to take all of your other home medications as prescribed. . please be sure to take all medication as prescribed. . please be sure to weigh yourself daily and record your weight. if you have more than a 3lb increase in your weight, please call you doctor immediately. . please be sure to keep all follow-up appointments with your pcp and heart doctor. . it was a pleasure taking care of you and we wish you a speedy recovery. followup instructions: please be sure to keep all follow-up appointments with your pcp and heart doctor. department: cardiac services when: thursday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage . with: dr. department: vascular surgery when: tuesday 10:00am location: suite c, phone: procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified arteriography of femoral and other lower extremity arteries arterial catheterization aortography automatic implantable cardioverter/defibrillator (aicd) check diagnoses: hyperpotassemia obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery esophageal reflux mitral valve disorders urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation aortocoronary bypass status other chronic pulmonary heart diseases percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified ulcer of other part of foot other specified forms of chronic ischemic heart disease dysthymic disorder other and unspecified hyperlipidemia long-term (current) use of insulin old myocardial infarction automatic implantable cardiac defibrillator in situ hypoxemia staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus acute on chronic systolic heart failure delirium due to conditions classified elsewhere other abnormal blood chemistry atherosclerosis of native arteries of the extremities with ulceration cellulitis and abscess of foot, except toes other sedatives and hypnotics causing adverse effects in therapeutic use posttraumatic stress disorder 

Answer: The patient is high likely exposed to