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: neupogen / neurontin / dilaudid attending: chief complaint: r foot tma ulcer major surgical or invasive procedure: debridement of r tma site ulcer and vac placement history of present illness: pt is 66 y/o m with h/o esrd on hd and peripheral disease s/p right transmetatarsal amputation one month ago for gangrene who presents with right tma site ulcer. patient has a history of occlusion of his popliteal artery and embolus to his distal vessels, which caused the grangrene for which required the tma. he is s/p angioplasty and stenting of his r popliteal artery. howver, he still developed necrosis of his tma site. he currently denies pain, redness, or drainage from tma site. no fevers, chills, chest pain, shortness of breath, abd pain, or nausea/vomiting. he will undergo debridement of his r foot tma site on . past medical history: pmh: 1) atrial fibrillation - s/p cardioversion in . was maintained on coumadin for 6 months. currently not anticoagulated due to fall risk. 2) pericardial effusion - s/p drainage, unclear etiology 3) esrd from atn in setting of acute gastroenteritis, s/p failed cadaveric kidney transplant in . dialyzed at tues, thurs, sat. 4) abdominal wall hernia - s/p repair after transplant 5) multiple knee surgeries 20 years ago 6) poor access, right tunnelled line 7) baseline sbp's in 90s 9) hypercapnia due to obesity hypoventilation syndrome 10) non-melanoma skin cancer 11) septic knee social history: denies any history of tobacco use, no etoh use for than 20 years, no drug use. lives with his wife, now on disability. used to work as a spray painter. has 3 children and multiple grandchildren. family history: history of cad (mother died at age 70), cancer physical exam: vs: t 99.5, hr 88, bp 96/62, rr 18, 96% ra gen: nad, a&o x 3 lungs: decreased bs b/l cv: irregularly irregular abd: soft, nt, nd ext: r tma site with 4 x 6 cm black eschar, no active purulent drainage, slight surrounding erythema vasc: 1+ fem b/l, dopp b/l, dopp pt b/l, dopp dp b/l pertinent results: portable tte (complete) done at 3:22:07 pm: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50%). right ventricular chamber size and free wall motion 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 structurally normal. there is no mitral valve prolapse. physiologic mitral regurgitation is seen (within normal limits). there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . 04:10pm blood wbc-4.9 rbc-2.87* hgb-8.6* hct-28.6* mcv-100* mch-30.0 mchc-30.1* rdw-17.6* plt ct-149* 07:20am blood wbc-6.1 rbc-3.05* hgb-9.4* hct-31.0* mcv-102* mch-30.8 mchc-30.3* rdw-19.1* plt ct-137* 01:12pm blood neuts-74.5* bands-0 lymphs-21.6 monos-2.6 eos-1.1 baso-0.2 04:10pm blood pt-15.3* ptt-32.8 inr(pt)-1.3* 04:10pm blood plt ct-149* 07:20am blood pt-14.5* ptt-32.7 inr(pt)-1.3* 07:20am blood plt ct-137* 04:10pm blood glucose-88 urean-16 creat-4.0*# na-140 k-3.4 cl-103 hco3-28 angap-12 07:20am blood glucose-37* urean-19 creat-4.8*# na-141 k-3.6 cl-101 hco3-29 angap-15 08:52am blood ck(cpk)-20* 09:40pm blood ck(cpk)-19* 02:26pm blood ck(cpk)-19* 08:52am blood ck-mb-notdone ctropnt-0.12* 09:40pm blood ck-mb-notdone ctropnt-0.10* 02:26pm blood ck-mb-notdone ctropnt-0.12* 07:20am blood calcium-8.4 phos-3.3 mg-2.0 06:55am blood vitb12-278 folate-16.5 01:12pm blood digoxin-0.8* 09:17am blood type- temp-36.1 rates-/22 fio2-97 o2 flow-6 po2-50* pco2-89* ph-7.10* caltco2-29 base xs--5 aado2-556 req o2-91 intubat-not intuba comment-off the di 10:40am blood type- po2-148* pco2-50* ph-7.39 caltco2-31* base xs-4 comment-green top . tissue site: foot rt foot tma debridement. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): no growth. anaerobic culture (preliminary): no growth. . 3:22 pm blood culture source: venipuncture. blood culture, routine (pending): . 1:13 pm mrsa screen **final report ** mrsa screen (final ): no mrsa isolated. . cxr: 1) probable small focus of atelectasis and pleural fluid or thickening posteriorly. the overall appearance is similar to prior lateral cxrs from and . in the absence of acute symptoms, this is unlikely to represent a focal infiltrate. 2) copd, cardiomegaly, and ? pulmonary hypertension. no chf. . path: right tma debridement: gangrenous necrosis of skin and soft tissue. . ekg atrial fibrillation with rapid ventricular response. diffuse low voltage and non-specific st-t wave changes. compared to the previous tracing of no diagnostic interim change. . us : impression: no right upper extremity dvt. brief hospital course: patient was admitted to the service on and was pre-op for r tma debridement. he was started on broad spectrum abx (vanc, cipro, flagyl) for tma ulcer. on , the patient went to the or for debridement of r tma site and vac placement. there were no complications intra-operatively, and the patient was extubated without difficulty. in the pacu, the patient dropped his blood pressure to the 70s diastolic, and his hr was in the 130s in an atrial fib/rvr rhythm. the patient was bolused with neo and started on a drip at 0.8. he also received a pulse dose of steroids. the patient responded with systolic pressures in the 90s. cardiology was contact to determine if the patient was a candidate for cardioversion, however they declined. they recommended to keep the patient on digoxin and lopressor for his arrhthymia, as long as the patient could handle it. the patient was then transferred to the cvicu for close monitoring. the patient was ruled out for an mi with troponins. of note, the patient had fluid and pressor adminstered through his catheter, as he had no other iv access. the patient's antibiotics were switched to vanc/gent with hd for empiric coverage. on , the patient was weaned off the neo gtt. he was evaluated by renal, who dialyzed the patient after administration of 25g of albumin. the patient received 1 pack of prbcs postop for hct of 27. his blood pressure was then maintained in the 90s-120s systolic. on , pod2, the team took down the patient's vac - his tma site appeared to be clean and healing very well. the plan was to change the vac again in days and to start looking for rehab placement. however, the surgery team was notified in the morning that the patient's sbp was in the high 60s and low 70s systolic, with hr in the 130s. the patient was evaluated by the service, who felt the patient would be best served by being monitored in the micu, as the only active issues for the patient were renal and cardiologic in nature. of note, the patient was evaluated by the renal service as well, who felt that the patient's blood pressure did not need to be treated if the map remained above 50 and if the patient was mentating well. the patient was then transferred to the micu. micu course: patient was started on antibiotics as per surgery, and received his hd on the icu floor. patient received an echo which demonstrated no significant change from previous, with no pericardial effusion. in addition, the patient was complaining of some right arm pain and received an upper extremity ultrasound which was negative for dvt. medicine floor course: transfered on . . # hypotension: pt with baseline low blood pressure in 90-100 without any symptoms. hypotension requiring icu care throught to be due to afib with rvr and improved back to baseline with rate control. tte nl without pericardial effusion and no evidence of infection; abx discontinued on . was hypotensive to 80s on with hypothermia to 95.5 but no evidence of infection still on cxr or blood cultures to date. bp improved and metoprolol restarted at low dose, to be uptitrated as tolerated. *** and blood cultures pending at discharge.*** . # afib with rvr: has h/o failed cardioversion. cardiology consulted and recommended medical management. he is not on coumadin fall risk but continued on asirin 325mg po daily. rate control between 80s and 100s was achieved with digoxin 0.125mg po qod and metoprolol 25mg tid. however, metoprolol discontinued and then restarted at lower dose of 12.5mg in setting of lower-running bp. would increase beta blockade for more optimal rate control as bp tolerates. . # hypoglycemia: on am the patient had a bg of 37, improved to 190 on fs after amp d50. unclear etiology. he is not diabetic, and on no meds which would cause hypoglyemia. no signs of infection. pt had been receiving prednisone in am but changed to qhs dosing as this has helped him avoid late evening and early am hypoglycemic episodes in the past. continue evening snacks and qid fsg monitoring. . # obesity hypoventilation syndrome: questionable history of obesity hypoventilation syndrome. abg showed respiratory acidosis with 7.10/89/50 but hypercarbia improved on vbg of 7.39/50/148. could consider outpatient pulmonary evaluation of hypercapnia. . # pvd s/p lma revision: no evidence of infection on arrival to the floor. vancomycin and zosyn discontinued on given the negative cultures. pt to continue wound vac until re-evaluation by dr. . he was continued on asa and plavix (course to be determined by surgery). pain controlled with tylenol and oral morphine. follow-up scheduled with dr. on at 10am. . # right arm pain: c/o right arm pain over the last few weeks after being pulled by the right arm. rue doppler u/s was done and negative for a dvt. pain contrlled with prn pain meds, phyical therapy. . # anemia: likely esrd; receives epo with hd. hct currently at his baseline. noted to be macrocytic, and b12 levels were borderline low. given the low toxicity and expense of vitamin b12 the patient was started on 1000mcg daily po vitamin b 12 supplementation. b12 levels showed be followed for improvement. . # esrd s/p failed renal transplant: on hd t/th/sa. continued on nephrocaps and vitamin a; sevelamer discontinued as phosphate low; to be restarted as needed. continued on home prednisone dose. he did receive stress dose steroids in the setting of hypotension but now back on home dose. adrenal insufficiency workup not pursued due to clear association of hypotension with afib with rvr and 5mg dose unlikely to suppress hpa axis. should receive prednisone at night to avoid hypoglycemic episodes at night and early am. . # mental status: alert and oreinted x 3 throughout floor course. . # fen: ivf prn, replete electrolytes - restart sevelamer prn, renal diet . # prophylaxis: subcutaneous heparin, ppi, bowel regimen. . # access: r sc tunneled hd line . # code: full . # communication: with patient. hcp is wife (). medications on admission: albuterol plavix 75mg po daily metoprolol 50mg po tid prilosec 20mg po daily prednisone 5mg po daily sevelamer 2400mg po tid with meals simvastatin 10mg po daily nephro-vite 1 capsule po daily vit a units po daily discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for wheezing. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. prednisone 5 mg tablet sig: one (1) tablet po at bedtime. tablet(s) 5. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. vitamin a 10,000 unit tablet sig: one (1) tablet po once a day. 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml (5000 units) injection tid (3 times a day). 8. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 14. heparin (porcine) 5,000 unit/ml solution sig: 4000- unit dwell injection prn (as needed) as needed for line flush: catheter (tunneled 2-lumen): nurse only: withdraw 4 ml prior to flushing with 10 ml ns followed by heparin as above according to volume per lumen. . 15. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 16. morphine 15 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. 17. nephro-vite 0.8 mg tablet sig: one (1) tablet po once a day. 18. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po twice a day: hold for sbp <90 or hr <60. discharge disposition: extended care facility: - discharge diagnosis: peripheral disease s/p right foot debridement atrial fibrillation with rvr esrd s/p transplant on hd anemia b12 deficiency discharge condition: good, bp stable, hr stable discharge instructions: you were admitted to for surgery on your right foot. your blood flow to your foot was poor and dead tissue had to be removed. after the surgery you developed low blood presure in the setting of a rapid irregular heart rate (atrial fibrillation). you were supported in the icu. your heart rate was controled with medications and your blood pressure improved. there was a concern for an infection in your foot but all cultures were negative and all antibiotics have been discontinued. your foot pain was treated with pain medicine and vac. you will continue to need intense wound care and physical therapy at the rehabilitation center as well as follow-up with surgery. . the following changes were made to your medication regimen: metoprolol tartrate was decreased to 12.5mg two times a day digoxin was added for heart rate control aspirin was started to thin the blood cyanocobalamin was started to replete vitamin b12 colace, senna, and bisacodyl were added for constipation sevelamer was discontinued tylenol and immediate release morphine were added for foot and shoulder pain . please follow up with your doctors as detailed below. . if you develop fevers, chills, dizziness, chest pain, palpatations, vomitting, diarrhea, shortness of breath, severe foot pain, or any other worrisome symptoms please call your doctor or go to the emergency room. followup instructions: pcp: . . please call to make an appointment within 1 week of discharge from the rehabilitation facility. . surgery: at 10am with dr . (. procedure: hemodialysis local excision of lesion or tissue of bone, other bones diagnoses: other iatrogenic hypotension thrombocytopenia, unspecified end stage renal disease cardiac complications, not elsewhere classified atrial fibrillation other b-complex deficiencies atherosclerosis of native arteries of the extremities with gangrene infection (chronic) of amputation stump hypoglycemia, unspecified 

Answer: The patient is high likely exposed to