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 attending: chief complaint: hyperglycemia major surgical or invasive procedure: incisions and drainages of left foot (bedside as well as in or) picc line insertion history of present illness: 73 yo m w/ dm2 (c/b left plantar ulcer), cad s/p mi and cabg (lima-lad, rsvg-cx, svg-pda, svgpl) who p/f () with nausea and sob. pt denies cp. notes that emesis started 4 days ago (once daily), none today. describes sob as doe that he has at baseline and not a new symptom. no oxygen requirement at . limited in his ability to ambulate to due diabetic ulcer on left foot, not limited by sob. of note patient has been poorly compliant with meds x 4 month and almost fully refusing meds x 3 days, notes that 4 months ago staff changed his room around not to his liking and 3 days ago again similar issue. stopped oral meds, continued insulin injections. confirms dnr/dni. . in the ed, initial vitals were 98.6 107 117/76 16 98% 4l. labs and imaging significant for bs>500, tnt 0.50, cr 1.6, ck 69, mb 5, wbc 13.7, 87.7%pmns, cxr showed pulmonary edema could not r/o pna, ed interpretation of ekg: ste 1mm avr/v1, std 1-2mm i, ii, l, v3-6, septal q's. he was seen by cardiology in the ed and it was explained to him that he may be having a stemi, but patient refused catheterization. . patient given glipizide 10mg, metformin 500, insulin 10 units, azithro, not started insulin gtt, not started on heparin gtt, no asa, no bb. bs from 565 to 480. dnr/dni (confirmed with nursing home). has left plantar diabetic ulcer treated every friday at with wet to dry dressing changes. . vitals on transfer were 103 103/68 27 98%. . vitals on arrival: nad, 100, 132/77, 24, 89-92% on ra. . overnight: did not allow lab draw, checked fsbg 230, did not want any interventions other than sq insulin, and some oral meds. refused heparin gtt, refused plavix, refused cath. no cp, no sob. fell while going to the bathroom, did not want assistance. past medical history: dm2 (diabetic foot ulcer treated at wound clinic every friday) dyslipidemia hypertension cabg (lima-lad, rsvg-cx, svg-pda, svgpl) bell's palsy diverticular disease w/hx gib social history: -tobacco history: smoked for 1 year in past 50 years ago -etoh: none currently briefly in past -illicit drugs: none - never married, no kids - former cpa - lives at family history: - father mi in 60s, no heart history in mother - brother alive, no heart history physical exam: admission: vs: 132/77, 100, 25, 89-93% on ra general: looks stated age, poor hygeine, poor odor, oriented x3, requires full control of situation and very clear about what he does and does not want done. heent: mmm, sclera anicteric, eomi, no pallor or cyanosis of the oral mucosa. poor dentition. neck: jvp seems to be to tragus? cardiac: tachycardic, +s1+s2, no m/r/g. lungs: on ra. crackles 2/3 up b/l. accessory muscle use. can speak in full sentences. abdomen: distended but soft, non tender, no rebound. extremities: pitting edema b/l left > right up to mid thigh, patietn did not allow visualization of left plantar ulcer, right toe nails yellow and dysmorphic. - no sensation up to knee on left lateral leg, right foot, left foot pulses: pt on left (did not allow dp), dp/pt on right discharge: vs: 98 94/57 p89 r16 99ra i/o: 1640/725 yest + bmx3 gen: seated in chair. in no apparent distress. lungs: cta b/l but limited excursion. cv: s1, s2 regular rhythm. no murmurs/gallops/rubs. back: no cva tenderness. no presacral edema extremities: 2+ pitting edema b/l. dorasalis pedis 2+ on right. left foot wrapped in bandage clean/dry/intact. ulcer covered in black eschar to left great toe. pertinent results: admission: 04:29pm blood wbc-13.7*# rbc-3.78* hgb-11.4*# hct-33.8* mcv-89 mch-30.0 mchc-33.6 rdw-16.3* plt ct-378# 04:29pm blood neuts-87.7* lymphs-8.4* monos-3.3 eos-0.5 baso-0.1 04:29pm blood pt-13.0* ptt-23.4* inr(pt)-1.2* 04:29pm blood glucose-452* urean-59* creat-1.6* na-134 k-4.4 cl-98 hco3-22 angap-18 04:29pm blood alt-40 ast-30 ck(cpk)-69 alkphos-87 totbili-0.4 04:29pm blood albumin-4.3 calcium-9.4 phos-2.8 mg-2.5 04:29pm blood ck-mb-5 04:29pm blood ctropnt-0.50* 08:37pm blood ck-mb-4 ctropnt-0.49* 04:19am blood ck-mb-4 ctropnt-0.49* interval: 01:00am blood %hba1c-10.9* eag-266* 07:35am blood crp-179.6* 06:15am blood crp-123.1* 06:05am blood ctropnt-0.36* 07:45am blood triglyc-80 hdl-34 chol/hd-2.8 ldlcalc-44 07:45am blood glucose-81 urean-32* creat-1.6* na-141 k-4.3 cl-109* hco3-23 angap-13 discharge: 05:53am blood wbc-5.7 rbc-2.99* hgb-8.7* hct-26.7* mcv-89 mch-29.2 mchc-32.7 rdw-15.8* plt ct-254 05:53am blood pt-14.5* ptt-33.1 inr(pt)-1.4* 05:53am blood glucose-67* urean-29* creat-1.9* na-142 k-4.7 cl-110* hco3-22 angap-15 05:53am blood calcium-8.4 phos-3.2 mg-2.1 imaging: portable chest: . findings: single portable view of the chest is compared to previous exam from . indistinct pulmonary vascular markings are seen bilaterally. blunting of the costophrenic angle and silhouetting the hemidiaphragm suggestive of bilateral effusions. cardiomediastinal silhouette appears enlarged, likely slightly accentuated by low inspiratory effort. median sternotomy wires are noted, now with a fracture of the top two wires. osseous and soft tissue structures are unremarkable. impression: findings suggestive of congestive failure with mild pulmonary edema and bilateral effusions. component of superimposed infection should be considered based on a clinical basis. abdomen (supine & erect) findings: supine and upright views of the abdomen were obtained. bowel gas pattern is unremarkable without dilated loops of small and large bowel. gas is present within the rectum. no fluid level or pneumoperitoneum is present on the upright exam. several metallic clips overlie the right femoral head, compatible with prior inguinal repair. sternotomy wires are intact. impression: normal bowel gas pattern without evidence of bowel obstruction. echo : conclusions the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. overall left ventricular systolic function is severely depressed (lvef= 25-30 %) with global hypokinesis and akinesis of the infero-posterior segments. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. 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 report of the prior study (images unavailable for review) of , the lvef has decreased foot ap,lat & obl left findings: no previous images. there have been resection of the phalanges and a portion of the metatarsal of the fifth digit. either previous infectious changes or surgical change about the metatarsophalangeal joints of the second, third, and fourth digits in this patient with vascular calcification consistent with diabetes. in the absence of previous images, it is extremely difficult to determine whether there could be acute osteomyelitis. mri would be the next imaging modality to attempt to make this clinical decision. venous dup ext uni (map/dvt) left lower extremity venous duplex findings: duplex evaluation was performed on the left lower extremity veins. there is normal compression and augmentation of the common femoral, proximal femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal veins. there is normal phasicity of the common femoral veins bilaterally. impression: no evidence of left lower extremity deep vein thrombosis. art ext (rest only) bilateral lower extremity abis, doppler waveforms and pvrs were performed at rest. findings: right: the right abis are 1.17/1.12 at dp/pt. right-sided doppler waveforms are triphasic at all levels with normal pvrs. left: the left abis are 1.12/1.17 at the dp/pt. left-sided doppler waveforms are all triphasic with normal pvrs. impression: no evidence of any peripheral vascular disease at rest. picc line placement : impression: uncomplicated ultrasound and fluoroscopically guided single-lumen picc placement via the right brachial venous approach. final internal length is 32 cm, with the tip positioned in svc. the line is ready to use. pathology/micro: diagnosis: bone, left foot, debridement: bone with reactive changes and granulation tissue with focal acute inflammation consistent with healing ulcer. see note. note: the findings may be compatible with treated/resolving osteomyelitis. clinical correlation is recommended. gross: the specimen is received fresh in a container labeled with the patient's name, ", ", medical record number and "left foot bone". it consists of a 3 x 3 cm aggregate of bone fragments; the largest fragment measures 2.2 cm in maximum dimension. the specimen is represented in a following decalcification. brief hospital course: 73m with pmh of cad s/p mi and 4 vessel cabg , dm2 complicated by multiple l foot ulcers, presented from for nausea, fsbg > 500 and poor med compliance. in ed found to have troponin t of 0.5, and non-specific st depression on ekg. he was also determined to have lle osteomyelitis, decompensated systolic chf, osteomyelitis and a uti. he is being treated with broad spectrum antibiotics for his lle osteomyelitis. his heart failure has attempted to be optimized but has been limited by fluctuating creatinine. delivery of care has also been hindered by psychiatric co-morbidities (e.g. narcissitic personality disorder) with patient refusing care at some times. . # cad with demand ischemia/troponinemia : on evaluation in the ed, he was found to have an elevated troponin (0.50) with st depressions in lateral leads on ekg, in the absence of chest pain. this was concerning for evolving stemi in the emergency department, so a cardiac catheterization was recommended, but patient refused intervention, even if this were stemi. in ccu pt was started on iv metop 10mg q6h for hr 60s-70s, asa 325mg and atorvastatin 80mg if patient agrees to take. pt transferred to medicine since he does not require ccu level of care and no potential cardiac interventions will be done. he was transferred to the ccu for further management. cardiology consult stated that he likely had demand ischemia from heart failure as discussed below and no apparent nstemi or stemi. there, he refused majority of medical care, including asa and clopidogrel. his troponins have remained stable (~0.4) with improvement of st depressions on ekg. his troponinemia was most likely demand ischemia/troponin spill in setting of chf and metabolic stress. not likely ischemic event. he remained chest pain free throughout his stay. # acute on chronic schf exacerbation (echo ef 50%): patient likely had decompensated systolic heart failure from infection and poor medication compliance. initially, patient had sao2 89-92% on ra with b/l crackles 2/3 up. at baseline pt does have doe but unclear distance he can walk given left foot ulcer limits mobility significantly. cxr showed significant pulmonary edema. patient had a tte this admission that demonstrated an ef of 25-30% (down from 50% approx 10 yrs ago). the patient was given furosemide diuresis after which his saturations and crackles improved. he was saturating well and without shortness of breath by the day of discharge. he is being discharged on a limited anti-ischemic regimen given sbp in 90s/low 80s including a statin. he should start lasix 20 mg po qd. future considerations should be re-starting metoprolol, acei when renal function stabilizes. . # osteomyelitis: patient was found to have a left foot ulcer with dry and wet gangrene of left toe and lateral foot, which on evaluation probed to bone and was purulent. he is being treated with iv vancomycin and cefepime. foot xray inconclusive. apparently, patient has been evaluated at hospital for this and recently (w/in a month) had an mri there. those records were unable to be obtained, but there was high clinical suspicion for osteomyelitis (secondary to elevated inflammatory markers, l foot lateral plantar lower extremity probes to bone and has purulence). podiatry consulted and performed bedside incisions and drainages followed by debridement under general anesthesia on . patient will follow-up with podiatry as scheduled. he is being discharged with a wet-to-dry and should have wound vac as instructed re-started at rehab. he should keep wound vac on until podiatry follow-up. . # refusal of treatment in setting of personality disorder - pt is very difficult to manage and will intermittently refuse various iv and po medications daily, despite understanding the risks and consquences. additionally, the patient would not allow any care whatsoever, including vital signs, repletion of vital electrolytes, antibiotics for his foot medications, heparin sq, etc during evening and nighttime hours. psychiatry was consulted and determined that he had the mental capacity to make decisions, even though he understood that he could die. social work was also consulted and determined from discussions with patient's hcp that pt "will often respond well to encouragement and reasoning behind a procedure/test but will 'dig his heels in' should he be told he needs to have something done." . # elevated fsbg: 565 in ed, ag = 14, fsbg fluctuates. home dose 40u lantus qhs. no signs and symptoms of dka or non-ketotic hyperosmolar come. hga1c 10.6. diabetes was consulted and assisted in the management of his blood glucose while an inpatient with a standing lantus and a humalog insulin sliding scale. his metformin and glipizide were discontinued and kept off at discharge due to significant noncompliance with po medications. . # acute vs chronic ckd? - cr this admission fluctuated between 1.5 to 2, which is consistent with osh records from earlier this year, but values down to 1.2 seen in records. increase here was likely secondary to diuresis vs poor renal perfusion in setting of schf. his cr was 1.9 on day of discharge. . # complicated cystitis secondary to e. coli resistant to cipro: he had evidence of infection on a urinalysis. he denied dysuria, but may have been confused so it was decided to treat as a uti. he was initially treated with cipro, but his e. coli was resistant so he was switched to cefepime for 7 total doses. patient lost iv access so missed 2 doses in the middle of the course. his course was also complicated by intermittent and unpredicatble refusal of medications at times. he was asymptomatic and urinating without issues by day of discharge. . # acute encephalopathy,toxic-metabolic, resolved: the patient's course was likely complicated by delirium, with report of aggression towards medical staff requiring administration of haldol in the ed and ccu. on the medical floor, psychiatry was consulted and by that time patient was alert and fully oriented as well as capacitated. . # lle swelling - remained stable during the admission. likely due to chf and/or pvd. lower extremity noninvasive imaging showed no dvt . # low normal bp/hypotension (systolic in high 80s to low 90s) - likely due to hypovolemia s/p diuresis. patient remained asymptomatic at all times, mentating at his baseline. offered compression stockings to help increase venous return, as patient spent all day in the chair and refused the bed unless it is nighttime. metoprolol and lisinopril held due to hypotension. by day of discharge his bp was stable with systolic 90s to low 100s with hr 80s. . # transitional issues: 1) patient is dnr/dni 2) weekly labs: chem 7 including bun, cr, esr, crp, cbc with differential 3) continue diabetes therapy 4) continue to advance heart failure therapy as above 5) continue wound vac for lle wound 6) monitor diabetes regimen and po intake medications on admission: preadmission medications listed are correct and complete. information was obtained from webomr. 1. metoprolol tartrate 50 mg po bid hold for sbp < 100, hr < 55 2. omeprazole 40 mg po daily 3. simvastatin 20 mg po daily 4. metformin (glucophage) 500 mg po daily 5. glipizide 10 mg po bid 6. lantus *nf* (insulin glargine) 40 u subcutaneous hs 7. aspirin 81 mg po daily 8. nitroglycerin sl 0.3 mg sl prn chest pain discharge medications: 1. aspirin 81 mg po daily 2. simvastatin 20 mg po daily 3. omeprazole 40 mg po daily 4. nitroglycerin sl 0.3 mg sl prn chest pain 5. ceftaroline 400 mg iv q12h d1 = for osteomyelitis. course to be determined by infectious disease. 6. furosemide 20 mg po daily hold for sbp < 100 7. heparin 5000 unit sc tid 8. glargine 20 units breakfast insulin sc sliding scale using hum insulin 9. metronidazole (flagyl) 500 mg iv q8h d1 = for osteomyelitis. 10. miconazole powder 2% 1 appl tp :prn groin rash 11. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 12. outpatient lab work fax weekly safety labs to the below infectious disease provider: , , .d. phone:( fax:( icd-9: 730 (osteomyelitis) start date: frequency: weekly labs: chem 7 including bun, cr, esr, crp, cbc with differential discharge disposition: extended care facility: northeast hospitial discharge diagnosis: primary: osteomyelitis secondary: acute on chronic systolic heart failure, complicated cystitis, diabetes mellitus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. discharge instructions: dear mr. : it was a pleasure caring for you at . you were admitted because you were found to have several issues, including very high blood sugars, worsening of your heart failure (characterized by fluid in your lungs and your legs), a serious infection of your foot, and a urinary tract infection. we treated you with insulin to control your sugar, antibiotics for your infections, and used a "water-pill" to remove fluid from your body. the foot doctors (podiatry) opened up and drained/removed some of the infected material of your foot. you will need to follow-up with the podiatry and infectious disease doctors for further . followup instructions: please follow-up with your primary care physician as below after discharge from rehab: , l. department: infectious disease when: tuesday at 3:30 pm with: , md building: lm campus: west best parking: garage department: podiatry when: friday at 3:30 pm with: , dpm building: ba ( complex) campus: west best parking: garage department: infectious disease when: wednesday at 11:30 am with: , md building: lm bldg () campus: west best parking: garage procedure: central venous catheter placement with guidance local excision of lesion or tissue of bone, unspecified site local excision of lesion or tissue of bone, unspecified site diagnoses: congestive heart failure, unspecified toxic encephalopathy acute kidney failure, unspecified coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status chronic kidney disease, unspecified other and unspecified hyperlipidemia long-term (current) use of insulin personal history of noncompliance with medical treatment, presenting hazards to health do not resuscitate status acute on chronic systolic heart failure diabetes with other specified manifestations, type ii or unspecified type, uncontrolled gangrene ulcer of heel and midfoot other bone involvement in diseases classified elsewhere unspecified osteomyelitis, ankle and foot other acute and subacute forms of ischemic heart disease, other other and unspecified escherichia coli [e. coli] diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled physical restraints status cystitis, unspecified narcissistic personality disorder encounter for change or removal of surgical wound dressing 

Answer: The patient is high likely exposed to