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: history of present illness: patient is a 69-year-old male with a history of diabetes mellitus type 2, hypertension, and chronic renal failure. over the past year, the patient has had increasing lower extremity edema and recurrent leg cellulitis. the patient was recently hospitalized at hospital (from until ) with complaint of weakness, chest heaviness, and shortness of breath. during his hospitalization, the patient was ruled out for a myocardial infarction, and was diuresed extensively with loss of 25 pounds. the patient complained of nausea, vomiting, and poor po intake, and underwent an egd, gastric biopsy was concerning for amyloidosis. the patient was subsequently transferred to for further workup. while on the medical service, the patient had two episodes of chest pain without electrocardiogram changes. his troponin was elevated to 1.1. on the morning following his transfer, the patient complained of nausea. he began to have episodes of hematemesis. his systolic blood pressure decreased to the 80s. the patient was administered intravenous fluids and was transferred to the micu for further management. past medical history: 1. non-insulin dependent-diabetes mellitus x15 years complicated by diabetic nephropathy. 2. chronic renal failure. renal biopsy in disclosed ssgs. baseline creatinine 2.5. 3. hypertension. 4. paroxysmal atrial fibrillation. 5. congestive heart failure. echocardiogram in at medical center disclosed concentric left ventricular hypertrophy, mildly decreased left ventricular function with an ejection fraction of 50-55%, rvh. 6. erosive esophagitis and gastritis with evidence of fold thickening and nodularity of the stomach. 7. coronary artery disease. cardiac catheterization in disclosed a 30% lesion in the marginal branch of the left anterior descending artery, and 30% lesion in the right coronary artery. remainder of coronaries satisfactory. 8. cellulitis of both legs. 9. malnutrition. 10. b12 deficiency. 11. depression. 12. anemia treated with iron supplementation and epogen. 13. plasma cell dyscrasia. bone marrow biopsy in disclosed 10% plasma cells. 14. prior episode of ischemic colitis diagnosed by colonoscopy . 15. history of spep showing three lambda-light chains and upep disclosing the presence of - proteins. social history: the patient is married. works as an accountant. denies use of tobacco, alcohol, and drugs. has three children and eight grandchildren. family history: significant for diabetes mellitus, no history of hypertension or kidney disease. medications: 1. glyburide 1.25 q day. 2. niferex 150 q day. 3. aldactone 25 . 4. lasix 120 tid. 5. aspirin 81 q day. 6. monthly b12 injections. 7. folate 1 q day. 8. zaroxolyn 2.5 q day. 9. potassium chloride 20 meq tid. inpatient medications on transfer: 1. famotidine 20 mg iv q12. 2. protonix 40 mg po q12. 3. celexa 20 q day. 4. reglan 10 qid. 5. carafate 1 tid. 6. megace 400 . 7. aspirin 81 q day. 8. allopurinol 100 q day. 9. lasix 100 q day. 10. multivitamin one q day. 11. folate 1 mg q day. 12. epogen 30,000 units subq 3x a week. 13. heparin 5,000 units subq . allergies: no known drug allergies. physical examination: general: pale elderly male appears depressed. vital signs: temperature 97.5, blood pressure 100/45, heart rate 63, respiratory rate 16, o2 sat is 98% on room air. heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light. extraocular movements are intact. oropharynx clear. neck: no jugular venous distention appreciated, no thyromegaly, no cervical lymphadenopathy. heart regular, rate, and rhythm, 2/6 systolic murmur at right upper sternal border. no rubs or gallops. lungs: crackles bilaterally at bases. abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, and no masses. extremities: dry and scaly skin changes on the lower extremities. no lower extremity edema. neurologic: alert and oriented times three. cranial nerves ii through xii are grossly intact. examination is otherwise nonfocal. laboratory data: white count 11.6, hematocrit 22.8, platelets 344. patient's baseline hematocrit is 35. chemistries: sodium 130, potassium 4.1, chloride 89, bicarb 30, bun 80, creatinine 2.4, glucose 126. calcium 8.1, magnesium 2, phosphorus 6.1. ck 20, troponin 1.1. pt 13.2, ptt 29, inr of 1.2. electrocardiogram: normal sinus rhythm at 80 beats per minute, normal intervals, normal p-r interval, left bundle branch block. chest x-ray: evidence of congestive heart failure with bilateral pleural effusions and atelectasis, cardiomegaly. as noted above, the patient was transferred to the micu on for treatment of gastrointestinal bleed. patient underwent upper endoscopy on . large amounts of clotted blood was noted in the antrum of the stomach. the gi service decided that they would repeat the egd when they could obtain better visualization of the stomach. hospital course by systems: 1. pulmonary: patient required intubation on for respiratory arrest due to mucus plugging. the patient underwent bronchoscopy at that time which disclosed thick purulent secretions in the left main stem bronchus. the patient was started on a course of broad-spectrum antibiotics (ceftazidime and vancomycin) to cover nosocomial pathogens. as noted above, the patient's chest x-ray disclosed the presence of bilateral pleural effusions. the patient underwent thoracentesis on . laboratory data was consistent with a transudative effusion. cytology cultures and gram stain were negative. due to the recurrent nature of the patient's pleural effusion, the patient required placement of bilateral chest tubes. patient underwent pleurodesis of the left sided chest tube. during his hospitalization, the patient's chest tubes have continued to drain significant amounts of pleural fluid. in addition, the patient has required repeated bronchoscopies during his micu stay due to recurrent purulent secretions. on , the patient was noted to have purulent secretions in the main stem bronchi and right lower lobe, consistent with a ventilator-associated pneumonia. bal culture disclosed presence of gram-negative rods. furthermore, on , the patient underwent bronchoscopy which disclosed moderate secretions and partial obstruction of the bronchus intermedius and left main stem bronchus. patient eventually was changed to imipenem and then meropenem for treatment of ventilator associated pneumonia. during his hospital stay, the patient was maintained on assist-controlled ventilation over the past few days. the patient has undergone trials of pressure support ventilation with a goal to wean the patient from the ventilator. 2. gi: as noted above, the patient underwent upper endoscopy on . large amounts of clotted blood was noted in the antrum of the stomach. on , the patient underwent repeat upper endoscopy. blood was noted in his stomach. in addition, the whole stomach was noted to have nodularity and erosions compatible with an infiltrated disorder. biopsies were done and pathology disclosed no evidence of neoplasm. however, it was noted that there was deposition of acellular pale eosinophilic material with a moderate degree of staining with red. the pathologist had included that this is an amyloid like substance, possibly light chains. since , the patient has not had any further episodes of hematemesis. however, he has had episodes of dark stools and clots per rectum. the patient has required a total of 13 units of packed red blood cell transfusions to maintain his hematocrit greater than 30 during his hospital stay. 3. cardiology: as noted above, the patient complained of chest pain early in his hospital stay, and was noted to have a troponin elevation to 1.1. echocardiogram was consistent with a restrictive cardiomyopathy with a normal ejection fraction. in early , the patient began to be hypotensive. a repeat echocardiogram was done to rule out pericardial effusion causing tamponade as an etiology of the patient's hypotensive. there was no evidence of pericardial effusion on the echocardiogram. due to concern for adrenal insufficiency, random cortisol levels were checked and the patient's cortisol level was found to be 15. he was started on a course of stress dosed steroids. furthermore, patient was noted to be febrile and there was concern for a distributive shock. patient has continued to demonstrate septic physiology during his hospital stay. on , dopamine was started, and the patient has required pressors for much of his micu stay. since , we are in the process of weaning off pressors. the patient continues to require multiple fluid boluses to maintain his blood pressure. 4. renal: as noted above, the patient has a history of chronic renal insufficiency due to ffgs and diabetic nephropathy. the patient's renal function has deteriorated during his hospital stay. renal service has been followed the patient and his renal decompensation was initially attributed to atn in the setting of the patient's gastrointestinal bleed. red staining of the patient's kidney biopsy from was negative for amyloidosis. during his micu stay, the patient had declining urine output. in addition, he had episodes of hematuria requiring placement of a three-way foley. patient's bun and creatinine continued to rise. a renal ultrasound did not disclose evidence of hydronephrosis. on , the patient was noted to have a two component pericardial friction rub. he was started on hemodialysis. hemodialysis has been difficult due to the patient's hypotension. however, he requires dialysis due to his worsening metabolic acidosis. the patient will have a permcath placed by transplant surgery. 5. heme: as noted above, the patient has required a total of 13 units of packed red blood cells during his hospital stay for a maintenance of a hematocrit greater than 30. the patient's last episode of hematemesis was . the patient is administered epogen at hemodialysis. 6. oncology: the hematology/oncology service has been following the patient. the patient meets three minor criteria for multiple myeloma, namely bone marrow biopsy with 10% plasma cells, positive upep, and igm less than 50. it is believed that the patient's gastric biopsy is consistent with a light-chain gastropathy, presumably from the multiple myeloma. chemotherapy has not been pursued during the patient's micu stay, but it is an option for the future. 7. infectious disease: as noted above, patient was started on broad-spectrum antibiotics to cover nosocomial pathogens on . during his hospital stay, multiple blood, fungal, sputum, and urine cultures have been sent to the laboratory for workup of a source of the patient's sepsis. on , the patient was noted to be positive for clostridium difficile. he has also had gram-negative rods and gram-positive cocci in his sputum. blood cultures have remained negative to date. ct scan of the chest and abdomen did not disclose evidence of an abscess. currently, the patient has been followed by the infectious disease service. he was treated with a seven day course of fluconazole for yeast in his sputum and urine. patient currently remains on flagyl for treatment of his clostridium difficile infection and meropenem for treatment for ventilator-associated pneumonia. 8. endocrine: patient has a history of diabetes mellitus. he has been maintained on an insulin drip during his micu stay. in addition, patient has been started on stress dosed steroids for treatment of adrenal insufficiency in the setting of sepsis. 9. nutrition: the patient has very poor nutritional status with an albumin in the range of .3. he has been maintained on tpn during his hospital stay. 10. neurology: while on the ventilator, the patient was maintained on versed and morphine for sedation. by , these sedatives were weaned off. the patient has been observed opening his eyes, yet currently does not respond to painful stimuli or commands. 11. vascular: on , it was noted that the patient had modeling of his feet and ischemia of his toes. pulses are detectable by doppler. vascular surgery consult has been obtained. it appears that the patient has gangrene of his right first toe. 12. prophylaxis: the patient has been maintained on pepcid and venodyne boots during his micu stay. the remainder of the hospital course will be dictated by the medical team, who takes over his care. , m.d. dictated by: medquist36 procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other endoscopy of small intestine insertion of endotracheal tube hemodialysis venous catheterization for renal dialysis thoracentesis biopsy of bone marrow temporary tracheostomy closed [endoscopic] biopsy of bronchus esophagogastroduodenoscopy [egd] with closed biopsy injection into thoracic cavity injection or infusion of oxazolidinone class of antibiotics diagnoses: congestive heart failure, unspecified acute posthemorrhagic anemia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other shock without mention of trauma multiple myeloma, without mention of having achieved remission hemorrhage of gastrointestinal tract, unspecified streptococcal septicemia 

Answer: The patient is high likely exposed to