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: no known allergies / adverse drug reactions attending: chief complaint: lethargy major surgical or invasive procedure: intubation, hemodialysis history of present illness: 63 yo m with diabetes, ckd, paroxysmal atrial fibrillation s/p recent ablation () found down by family members for uncertain duration. altered, hypotensive, bradycardic, and with fingerstick of 134 with ems. . upon arrival to the ed vitals were: t 96.7, hr 38, bp 125/73, rr 13, o2sat 100% nrb. had sinus brady upon arrival with qrs of 168. got calcium and multiple amps of bicarb. was intubated with 8.0 tube, though difficult intubation. with 5+ bicarb pushes, qrs narrowed and hr increased. because of these findings, patient placed on bicarb drip. toxic ingestion was entertained and toxicology consult was called. given hypotension and bradycardia, patient started on dopamine at 10 mcg. given hypotension, was given 4l ns, had rij central line place, and vanc/zosyn for epiric treatment of sepsis. 600 mg aspirin given for potential mi. patient had multiple imaging studies in ed including ct head, ct c-spine, ct chest/abd/pelvis, all had essentially and cxr. vitals prior to transfer to the micu were: hr 70, bp 162/67, rr 23, o2sat 100% on ac 550 by 20 with peep 5 and fio2 100%. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: - cabg: none - percutaneous coronary interventions: ptca/stenting of pda - pacing/icd: none 3. other past medical history: - past medical history: diastolic dysfunction hypertension, severe diabetes mellitus, type ii c/b retinopathy, nephropathy, and neuropathy chronic infected diabetic ulcer paf on coumadin osa peripheral edema hyperlipidemia bph obesity gerd social history: lives with girlfriend. retired; formerly worked as bus driver with . denies alcohol, tobacco, or illicit drug use. family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. brother with diabetes mellitus. physical exam: vs: t 95.2, hr 68, bp 174/89, o2sat 95% 550x24, peep 8, fio2 70% gen: intubated, sedated heent: right surgical pupil, left pupil 3 mm and reactive, et and og tube in place neck: large circumference, rij triple lumen and lij dialysis cath in place pulm: ctab anteriorly with transmitted vent sounds card: bradycardia, nl s1, nl s2, no m/r/g abd: bs+, distended, tympanic, ext: ble edema with skin changes as below skin: ble with icthyosis and rle with verrucous skin changes and ulceration neuro: withdraws to pain, does not spontaneously open eyes or follow commands pertinent results: admission labs: 10:40pm blood wbc-9.0 rbc-3.89* hgb-10.8* hct-35.7* mcv-92# mch-27.7 mchc-30.2* rdw-17.1* plt ct-165 10:40pm blood neuts-73.1* lymphs-19.8 monos-4.7 eos-1.9 baso-0.5 10:40pm blood pt-19.0* ptt-31.8 inr(pt)-1.7* 10:40pm blood glucose-137* urean-150* creat-7.3*# na-134 k-8.6* cl-105 hco3-8* angap-30* 10:40pm blood alt-23 ast-31 ck(cpk)-383* alkphos-104 totbili-0.1 10:40pm blood lipase-93* 10:40pm blood ctropnt-0.08* 10:40pm blood ck-mb-10 mb indx-2.6 10:40pm blood albumin-4.3 calcium-8.6 phos-12.5*# mg-2.6 10:40pm blood osmolal-344* cxr: 1. endotracheal and nasogastric tubes in appropriate position. 2. low lung volumes. perihilar opacities may relate to pulmonary edema, although underlying aspiration cannot be excluded. 3. enlarged cardiac silhouette. prominent superior mediastinum, may relate to supine, ap technique. recommend clinical correlation and consider ct as clinically warranted. ct chest: 1. moderate bibasilar dependent atelectasis with focal consolidations, which may represent aspiration. enlarged pretracheal lymph node, likely reactive. 2. numerous mesenteric and paraaortic lymph nodes. 3. small sacular aneurysm of the infrarenal portion of the aorta, measuring 2.6 cm in transverse diameter (on coronal image). follow-up ultrasound in 6 months can be performed to assess stability, given the lack of comparison studies. 4. small hiatal hernia. 5. fat-containing left inguinal hernia. tte: impression: stiff left ventricle with impaired relaxation and preserved ejection fraction; moderate pulmonary hypertension with a dilated hypocontractile right ventricle renal u/s: normal renal ultrasound as described. brain mri: impression: 1. a small focus of subacute hemorrhage seen in the right occipital lobe not visualized on ct but seen as t1 hyperintensity on mr images with restricted diffusion in the center on diffusion-weighted images. 2. moderate-to-severe changes of small vessel disease and brain atrophy seen. 3. chronic infarcts in cerebellum and pons. 4. no mri signs of posterior reversible encephalopathy syndrome. brief hospital course: this is a 63 year old gentleman with diabetes, ckd, paroxysmal atrial fibrillation s/p recent ablation () found down by family members for uncertain duration. altered, hypotensive, bradycardic, found to be acidemic, hyperkalemic on admission. . # acidemia/acute on chronic renal failure: on admission, patient was tested for ingestion, and had negative serum ethanol, methanol, aspirin and ethylene glycol. etiology of renal failure felt to be acute on chronic in the setting of over-diuresis due to recent increase in dose to 160mg from 120 qam, 80qpm. renal was consulted on admission and placed a temporary l ij dialysis line. renal ultrasound was normal. his renal failure, hyperkalemia gradually resolved without dialysis. patient maintained good urine output throughout his icu stay. his renal function continued to improve with creatinine on discharge 2.8. he was discharged on 80mg lasix. . # respiratory failure: intubated for airway protection in ed given obtunded state. he was weaned from the ventilator and extubated without complication. he was completeley weaned off oxygen by discharge. . # uremic metabolic encephalopathy: on admission neurology was consulted. eeg was consistent with metabolic encephalopathy and mri demonstrated mp evdidence of pres. it is thought that his acute change in mental status was most likely secondary to uremia. as his renal failure returned to his baseline, his mental status improved. a small focus of subacute hemorrhage was seen in right occipital lobe was visualized and on review by neurology felt to be chronic. chronic small vessel disease and brain atrophy also noted. . # atrial fibrillation: while in the icu, a 20-minute episode of a-fib with rvr to 180s initially, then > 150s sustained. bp initially fell to 90s but then rebounded without intervention. the patient received 5mg iv metoprolol and returned into normal sinus rhythm and was countinued on coumadin and restarted on oral metoprolol. . # hypertension: the patient's extubation complicated by significant hypertension with systolic blood pressures into the 220s. his home dose of hydralazine was increased and metoprolol uptitrated. . # elephantiasis verrucosa nostra: dermatology was consulted and recommended amlactin lotion and leg wraps. . # hypernatremia: patient was initially hypernatremic to the 150s consistent with over diuresis. this resolved with iv d5w. . # troponin elevation: troponin t was elevated at 0.23 secondary to demand ischemia. echocardiogram demonstrated diastolic dysfunction, but no focal wall motion abnormalities of the lv. . # diabetes mellitus type 2: the patient was treated with insulin sliding scale while admitted. he was discharged on his home dose of novalog and nph. he was instructed to regularly check his fingersticks and to call his physician if his blood sugar was 60. . transitional issues # medical mangagement: increased hydralazine to 75mg tid, lasix 80mg , recommend outpatient evaluation of sleep apnea # code status: full medications on admission: 1. simvastatin 160 mg tablet 2. calcium acetate 667 mg tablet tid with meals. 3. vitamin d 50,000 unit capsule sig: qweek 4. furosemide 80 mg tablet 1 5. hydralazine 50 mg tablet 1 tablet po q8h 6. humalog 100 unit/ml iss 7. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: 8. isosorbide mononitrate 30 mg tablet sr qdaily 9. metoprolol succinate 100 mg sr 10. omeprazole 20 mg capsule, qdaily 11. warfarin 5 mg tablet qdaily on weekdays and 4mg on weekends 12. aspirin 81 mg tablet, qdaily 13. nph insulin fourteen (14) units subcutaneous qdaily : take before breakdast, take 10 units of nph before dinner. discharge medications: 1. simvastatin 80 mg tablet sig: one (1) tablet po once a day. 2. calcium acetate 667 mg tablet sig: one (1) tablet po three times a day: with meals . 3. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week. 4. lasix 80 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 5. hydralazine 50 mg tablet sig: 1.5 tablets po three times a day. disp:*135 tablet(s)* refills:*2* 6. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: one (1) inhalation once a day as needed for shortness of breath or wheezing. 7. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 8. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po twice a day. 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 10. warfarin 2 mg tablet sig: 1.5 tablets po once a day. disp:*45 tablet(s)* refills:*2* 11. aspirin 81 mg tablet sig: one (1) tablet po once a day. 12. ammonium lactate 12 % lotion sig: one (1) appl topical (2 times a day). disp:*1 bottle* refills:*2* 13. compression stockings please provide patient with compression stockings. diagnosis: elephantiasis verrucosa nostra 14. outpatient lab work reminder!! please have your electrolytes and inr checked at your next clinic appointment. 15. nph insulin human recomb 100 unit/ml suspension sig: one (1) subcutaneous once a day: take 16 units before breakfast and dinner. 16. novolog 100 unit/ml solution sig: take 12 units with each meal subcutaneous three times a day. discharge disposition: home with service facility: vna discharge diagnosis: 1. acute renal failure (diuretic overdose) 2. diabetes type 2, chronic kidney disease, elephantiasis verrucosa nostra 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 were admitted for evaluation of loss of consiousness. you were found to be in profound renal failure which caused a build up of toxins and likely contributed to your altered mental status. you were intubated to protect your respiratory function and a hemodialysis catheter was placed to clean your blood. the breathing tube was ultimately taken out and you were transferred back to the floor for further management where you did well and your kidney function continued to improve. while it is unclear why you developed acute kidney failure, it may be have occurred in the setting of a recent increase in your daily lasix dose. you had an episode of elevated blood pressure and atrial fibrillation while hospitalized. your daily hydralazine dose was increased. your legs were evaluated by our dermatologists who determined you had elephantiasis verrucosa nostra. a new cream was prescribed, amlactin which should be applied twice daily. compression stockings should prevent further progression of these skin changes. please continue your insulin regimen that you were taking at home. no changes were made to these medications. please discuss your diabetes managment with your primary care physician. continue to check your blood sugars. if you have a blood sugar < 60, please stop taking your medications and call your physician . the following medication changes were made: 1. decrease coumadin to 3mg daily 2. increase hydralazine to 75 mg three times daily 3. decrease lasix to 80mg twice a day 4. start lactic acid 12% lotion (amlactin), apply twice daily to your legs 5. start compression stockings as tolerated please follow up with your primary care physician next week to have a blood pressure check, an electrolyte check and to have your inr checked. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: name: , j location: - address: 291 independence dr, , phone: appointment: tuesday 10:20am you appointment for friday has been cancelled and was rescheduled with the appointment above. **you need to become established with a dermatologist and make an appointment within 1 month. please discuss this with your primary care physician at this appointment. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances venous catheterization for renal dialysis arterial catheterization diagnoses: acidosis hyperpotassemia obstructive sleep apnea (adult)(pediatric) acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes ulcer of other part of foot other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) acute respiratory failure cardiogenic shock diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin long-term (current) use of anticoagulants altered mental status obesity, unspecified metabolic encephalopathy hyperosmolality and/or hypernatremia diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled chronic diastolic heart failure diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled background diabetic retinopathy cerebral atherosclerosis other diuretics causing adverse effects in therapeutic use other lymphedema other fluid overload viral warts, unspecified 

Answer: The patient is high likely exposed to