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: penicillins / hayfever attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: history of present illness: 72 m s/p renal transplant and crf, diastolic chf ef 45-50%, s/p cabg and on coumadin, dm2, vasculopath with l fem- bypass and revisions, chf, recently discharged from after a 2 month admission for osteomyelitis, arf, and chf exacerbation. today he was sent from nh to for decreased responsiveness and ams intermittantly over last week. bg was found to be 34 with rapid recovery in responsiveness with d50. found him to be hyperkalemic in arf, with tnt 0.367 (same as troponin here). transferred to today because of his 2 month admission here recently. . family reported increasing full body swelling and worsening dyspnea from baseline for the past week. ekg shows 1.5 mm ste in v1-v3, 1mm on old ekgs for comparison. patient is dnr/dni, patient and family did not wish to have cardiac cath performed. patient has never had cp, but has had intermittent dyspnea. . in the ed, hr60s, bp105-110, 99% 2l nc, bg108, received asa, plavix, did not give integrillin because of renal failure. inr 4.9 for anticoagulation for , heparin gtt was not started. for hyperkalemia of k 5.9 and 6.0, patient received calcium, insulin, glucose, and he had received kayexylate at osh. cxr shows pulmonary edema and bilateral effusions. trop 0.38, mb 8, no ck drawn. . . micu course: found to be in oliguric renal failure with decreased urine output for 5 days prior to admission. started hemodialysis on for uremia, volume overload. supratheraputic inr on admission, unable to biopsy kidney for diagnosis, given vit k. inr subtheraputic (with goal 2.5-3.5), restarted on coumadin and heparin gtt until coumadin theraputic. also given solu-medrol 500mg x3 days to treat for rejection. . past medical history: - iddm - pvd - cad (no mi) - hyperlipid - hypertension - cri (baseline cr 1.5-1.7) - s/p l ak -dp spliced bpg () - s/p lrkt (') - s/p cabg/mech.(') - s/p excise l metatarsal head - s/p l av fistula (') - s/p excise colon polyp (') social history: non-contrib family history: non-contrib physical exam: vs: 97.9 / 108/36 / 63 / 12 / 99% 2l nc general: alert, communicating, answering questions and directing properly heent: jvd to jawline, no lad lungs: clear anteriorly but rales posteriorly, dull in bases bl heart: rrr, clear s1/s2, no m/r/g, cabg scar abdomen: soft, dependent 4+ edema, thin, +bs extr: 4+ edema on arms and legs, dopplerable pulses, larger r arm than left, cellulitis and eschars in r and l feet neuro: sensation present in legs and feet, cannot move legs well skin: skin breakdown areas . pertinent results: repeat echocardiogram conclusions: the left atrium is dilated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is moderate global left ventricular hypokinesis (lvef = 30-40 %). right ventricular chamber size and free wall motion are normal. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is a trivial/physiologic pericardial effusion. suboptimal image quality - patient unable to cooperate. compared with the findings of the prior study (images reviewed) of , the findings are similar (ejection fraction overestimated on prior study). . head ct impression: 1. no evidence of hemorrhage or mass effect. 2. central involutional changes and evidence of small vessel angiopathy. . echocardiogram:. conclusions: the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-5mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild global left ventricular hypokinesis (lvef = 50 %), no regionality seen. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. right ventricular systolic function is borderline normal. there is abnormal septal motion/position. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , no significant change. . cxr - impression: new consolidation in the right lower lobe that may reflect aspiration. followup radiographs will help distinguish atelectasis from pneumonia. interval improvement in pulmonary edema. . renal transplant u/s doppler examination of the main transplant renal artery and interpolar arterials demonstrates normal systolic upstroke with absent diastolic flow. the resistive index is 1.0. this is not significantly chnaged. the transplant renal is patent. impression: 1. stable appearance of transplant kidney with elevated resistive indeces. no evidence of hydronephrosis or perinephric collection 02:20am wbc-6.1 rbc-3.88* hgb-10.5* hct-34.1* mcv-88 mch-27.0 mchc-30.7* rdw-18.8* 02:20am neuts-77.1* lymphs-13.5* monos-7.8 eos-1.4 basos-0.2 02:20am plt count-241 02:20am pt-43.0* ptt-44.0* inr(pt)-4.9* 02:20am albumin-2.3* calcium-7.7* phosphate-5.5*# magnesium-2.0 02:20am ck-mb-8 ctropnt-0.38* 02:20am lipase-9 02:20am alt(sgpt)-10 ast(sgot)-17 alk phos-131* amylase-27 tot bili-0.2 02:20am glucose-88 urea n-57* creat-4.8*# sodium-139 potassium-6.0* chloride-114* total co2-13* anion gap-18 06:00am urine blood-lg nitrite-neg protein-100 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 06:00am urine color-amber appear-hazy sp -1.019 06:00am urine hours-random urea n-246 creat-176 sodium-25 potassium-56 chloride-17 tot prot-230 prot/crea-1.3* 05:19am lactate-1.1 k+-4.7 brief hospital course: 72 yo m s/p renal transplant and crf, systolic chf s/p cabg and on coumadin, dm2, vasculopathy with l fem- bypass and revisions admitted with mental status changes and acute renal failure with volume overload admitted to the micu. . micu course: found to be in oliguric renal failure with decreased urine output for 5 days prior to admission. started hemodialysis on for uremia, volume overload. supratheraputic inr on admission, unable to biopsy kidney for diagnosis, given vit k. inr subtheraputic (with goal 2.5-3.5), restarted on coumadin and heparin gtt until coumadin theraputic. also given solu-medrol 500mg x3 days to treat for possibility of transplant rejection. . # acute on chronic renal failure s/p renal transplant: he was continued on dialysis mwf throughout admission to treat uremia and volume overload secondary to acute renal failure. in evaluating the cause of his renal failure, initially the concern was for transplant rejection and he was given pulse steroid treatment in the micu. however, per report renal biopsy was consistent with diagnosis of diabetic nephropathy, with mod-severe scarring as well as atn. throughout the course of the admission he did not regain any significant return of renal function and continued to have a medical course complicated by volumve overload between dialysis with hypotensive episodes during dialysis. tacrolimus was restarted approximately 2 weeks in the admission and he was continued on mycophenolate and prednisone which he had been taking all along. one week before he expired he decided along with his family to be cmo. dr. was contact and spoke with the family. immunosupressants were initially left on his regimen for fear of acute rejection which could be painful but were slowly taken off. morphine, ativan and ondansetron were used for comfort. . #afib with rvr - on he went into afib with rvr following dialysis thought most likely to volume shifts. initially his rhythm was controlled with diltiazem however this was changed over to digoxin for a brief time followed by metoprolol for rate control. it was the feeling of the renal team that diltiazem should be avoided as it effects tacrolimus levels. he did not tolerated rapid atrial fibrillation and had associated shortness of breath and tachypnea when his rate was poorly controlled. within one week of the development of afib he spontaneously returned to sinus rhythm. lopressor 50mg po tid was continued for rate control while bp tolerated. when he was made cmo lopressor was discontinued. . #altered mental status/delirium - following the development of atrial fibrillation he developed acute mental status change characterized by fluctuating mental status, periods of confusion and disorientation, visual hallucinations and inability to speak. the etiology of this change was unclear however in evaluation of this he was found to have suffered an nstemi with troponins levle of 2.47 and trending down. unclear when original ischemic event occurred but was thought to be most likely due to demand ischemia in the setting of rapid afib vs. hypotension. other likely contribution to delirium includes medication effect with possible contributors including ativan which he was taking prn for anxiety, digoxin which was given briefly for afib and mirtazapine which was started for depression and poor appetite. infection was also a concern as he is immunosuppressed and seriously ill. he was treated empirically with vancomycin and levofloxacin. there was no evidence of ich on head ct and blood cultures remained negative. one week before he expired, his mental status cleared and he was awake, alert and oriented. it was at that point he made the decision to be cmo. . #nstemi/cad, s/p mechanical aortic valve replacement - as discussed above in investigating his acute mental status change he was found to have elevated troponin of 2.47 which was already trending down. unclear when original event occurred however it was likely due to demand ischemia in the setting of episodic hypotension or rapid atrial fibrillation. he was managed medically as the family did not want any drastic intervention given his multiple comorbidities. he was already on heparin gtt to bridge until inr theraputic (goal 2.5-3.5 for ), statin and metoprolol for rate control. aspirin was restarted. he had an echocardiogram to evaluate heart function following nstemi. while the report shows decreased ef of 30-40% it was ready by dr. who stated that no significant change from prior echocardiogram as he felt that ef was overestimated on prior report. . #shortness of breath and periodic desaturation - multiple causes of these symptoms throughout his admission including afib with rvr, increasing pulmonary edema associated with volume overload in between dialysis sessions. in addition poor nutrition and hypoalbuminemia likely contributing to his persistent pleural effusions. he was treated with supplemental o2 via nc as needed, dialysis for volume overload and rate control for afib. dialysis was discontinued after his decision to be cmo, supplemental o2 via nc and morphine were used for comfort. . # systolic heart failure: ef 30-40% by most recent echocardiogram with overal cardovascular status worsened by volume overload associated with renal failure as well as malnutrition and hypoalbuminemia. not reponsive to lasix given arf. treated for volume overload with hemodialysis. . #constipation - treated with standing colace and senna, and dulcolax suppository prn . #yeast on ua/uc- foley catheter was removed and he was treated with fluconzole . # osteomyelitis: recent 2 month admission for debridement of l foot/amputation at level of metatarsals, also has r foot heel eschar. both appear as uninfected dry gangrene at this time. has had prior l fem- with revisions . seen by podiatry during this admission with reccs for wound care as well as non weight bearing on l foot. he should follow up with dr. within 1 wk of discharge . # dm2, insulin-dependent: he was continued on insulin sliding scale, which was discontinued after he was made cmo . # cdiff: completed course of flagyl . # anemia: stable hct throughout admission, likely due to renal failure and chronic disease. . # history of depression/anxiety/panic: pt reports occasional anxiety, has been assessed by psychiatry in past admission, had recommended ativan regimen. he was intially treated with ativan 0.5mg prn which helped his symptoms however ativan was discontinued upon development of acute mental status change. in addition he was started on remeron to treat symptoms of depression and anorexia however this was also stopped in evaluating cause of acute mental status change. . #hypoalbuminemia/malnutrition - he had a very poor appetite and limited oral intake throughout admission with low albumin and malnutrition likely due to combination of chronic illness and depression. ntrition was consulted and he was started on liquid meal supplements however he took in very little of this. given the severity of his illness and families resistance to invasive treatment measures and consideration of cmo status tube feeding was not started. . ppx: ppi, on heparin gtt while waiting for inr be 2.5-3.5 (goal inr 2.5-3.5 for ) . code: dnr/dni, family does not want pt transferred to icu, made cmo medications on admission: medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 4. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. mycophenolate sodium 180 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 6. insulin take as directed by your pcp 7. glargine take 13 units at night / if you are on ss please take as directed by your pcp 8. warfarin 2.5 mg tablet sig: one (1) tablet po at bedtime: have your inr followed. you must get this done beginning tomorrow. tablet(s) 9. cefepime 10. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 5 weeks: last dose 9/18. 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 13. eplerenone 25 mg tablet sig: one (1) tablet po daily (daily). 14. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). 15. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 16. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). 17. papain-urea 830,000-10 unit/g-% ointment sig: one (1) appl topical (2 times a day). 18. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 19. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 20. mycophenolate sodium 180 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 21. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). 22. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime). 23. epoetin alfa 10,000 unit/ml solution sig: one (1) ml injection qm-w-f (). 24. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 25. metoclopramide 10 mg tablet sig: one (1) tablet po qid (4 times a day) as needed. discharge medications: none discharge disposition: expired discharge diagnosis: respiratory failure acute on chronic renal failure insulin dependant diabetes mellitus - iddm (may be dm2 insulin-dependent) - pvd- chf (ef 40-50% by echo) - cad s/p cabg + (') - hyperlipidemia - hypertension - cri (baseline cr 1.5-1.7) - s/p l -dp bypass followed by l tma with revision - s/p lrkt (') - s/p cabg/mech.(') - s/p excise l metatarsal head - s/p l av fistula (') - s/p excise colon polyp (') discharge condition: expired discharge instructions: none followup instructions: none md procedure: hemodialysis closed [percutaneous] [needle] biopsy of kidney diagnoses: hyperpotassemia anemia in chronic kidney disease subendocardial infarction, initial episode of care congestive heart failure, unspecified acute kidney failure, unspecified unspecified protein-calorie malnutrition candidiasis of other urogenital sites hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status chronic kidney disease, unspecified systolic heart failure, unspecified heart valve replaced by other means complications of transplanted kidney 

Answer: The patient is high likely exposed to