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: altered mental status, need for bipap major surgical or invasive procedure: central line placement arterial line placement endotracheal intubation history of present illness: is an 83 yo female with morbid obesity, dmii, diastolic chf, asthma, and pemphigus folleacious, and a recent 20-day admission for complex wound care for worsening skin sloughing and bullae and severe pain, who is now transferred back from rehab for hypoventilation in the setting of narcotic administration. during her admission, her pemphigus skin lesions were thought due to cmv/hsv with psuedomonal superinfection, and she had chronic narcotic requirements (at one point was on dilaudid pca in icu). she was d/c'ed to rehab on . of note, she was persistently hypothermic during her admission and was d/c'ed to rehab with a temp of 92.9. since that time, she has continued to have lots of pain, possibly post-herpetic, with all turns, movements, etc. per her daughter, she has been "getting too much pain medication." today, with her turning and cleaning in bed, she got 2mg iv dilaudid, then 2mg again. after that she was noted to be hypopneic, altered/less responsive, and was referred to ed. . in ed, vs: hypothermic to 85.8, 62, 138/78, 6, 100% on bipap. got 0.1mg narcan, with improvement in repsiratory rate to 18-20. lungs were noted to be wheezy, but no crackles were heard. she was given a nebulizer treatment and solumedrol. cxr showed stable mild cardiomegaly with increased perihilar opacities reflecting volume overload and atelectasis. she complained of difficulty breathing and was placed on bipap 14/4/100%. abg on these settings was 7.33/55/579, so fio2 was decreased to 50%. shortly thereafter, her sbp briefly dropped down to 90s, and she got 500cc bolus with reutn of bp's to 110s. ekg showed nsr at 70, na/ni, diffuse tw flattening. no effusion was seen on bedside ultrasound. ce's negative. other labs showed normal wbc count, stable anemia, and new thrombocytopenia to 109, as well as renal insufficieny (cr 1.3, was 0.7 on d/c, but by report has cri with baseline 1.3). lactate was 3.6. urine and blood cultures were sent and she was given vancomycin 1g and levofloxacin 750mg. access is with her picc line. most recent vs: rectal temp 88 67 14 108/71 100% on bipap. hypothermia was only addressed later in her ed course, with plan to begin warming down in ed and to check tsh. past medical history: chronic diastolic heart failure - repeat echo with ef 75% diabetes mellitus, type 2 on insulin chronic kidney disease, stage 3, baseline cr 1.3-1.5 obesity hypertension colostomy for diverticulitis asthma pemphigus foliaceus diagnosed last admission, with cmv/hsv superinfection (in addition to disseminated cmv/hsv disease) macrocytic anemia, unclear etiology dyslipidemia sacral decubitus ulcer, stage 2 social history: never smoked, no alcohol use. retired from the school district after 32 years. family history: no history of any severe dermatologic issues. physical exam: vitals: 31.5 (88.7) 66 121/59 10 100% on 2l general: obese, eldery, anasarcic african american female, no acute distress, lethargic but rousable heent: anisocoria, l>r, with sluggush light reaction, adentulous neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: distant hs, regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, + ostomy in llq, no organomegaly gu: foley in place. ext: cold to touch, anasarcic skin: diffuse hypopigmented lesions and desquamated skin rash most severe in intertriginous areas, as well as surrounding stoma, upper chest, face, and sacral area. estimated that desquamation covers approx 30-40% bsa. none of the lesions appear infected. . on : physical exam vitals: t97.1, bp116/41, hr86. rr18, o2sat100% on face mask, 96% on ra gen: alert and oriented x3, pleasant, nad heent: eomi, ncat, normal oro/nasopharynx, moist mucus membranes neck: soft, supple, rij in place - c/d/i, no jvd but unable to assess clearly given body habitus cv: rrr, no murmurs, gallops, rubs, normal s1/s2 pulm: scattered wheezes, bibasilar crackles but distant lung sounds - no rhonchi/rales abd: soft, +bs, non-tender, non-distended, morbidly obese, colostomy sink c/d/i with pink granulation tissue ext: 1+ pitting edema bilaterally to above the knees, symmetrical, pulses intact neuro: moves arms and legs but with proximal weakness skin: pemphigus lesions (purplish papules with yellowish, hypopigmented reticular borders pertinent results: cbcs: 04:07pm blood wbc-5.1 rbc-2.90* hgb-8.6* hct-31.2* mcv-108* mch-29.8 mchc-27.6* rdw-19.1* plt ct-109* 09:43am blood wbc-6.2# rbc-2.19* hgb-6.8* hct-22.4* mcv-103* mch-31.3 mchc-30.5* rdw-19.5* plt ct-81* 03:47am blood wbc-6.4 rbc-3.14* hgb-9.7* hct-30.9* mcv-98 mch-30.9 mchc-31.5 rdw-19.9* plt ct-81* 12:31am blood wbc-8.0 rbc-3.07* hgb-9.8* hct-29.8* mcv-97 mch-31.9 mchc-32.9 rdw-18.9* plt ct-55* . chems: 04:07pm blood glucose-217* urean-30* creat-1.3* na-136 k-3.2* cl-98 hco3-30 angap-11 03:20am blood glucose-176* urean-28* creat-1.1 na-141 k-3.8 cl-111* hco3-25 angap-9 02:44am blood glucose-397* urean-39* creat-1.2* na-136 k-4.1 cl-108 hco3-23 angap-9 02:43am blood glucose-98 urean-47* creat-1.5* na-140 k-3.8 cl-109* hco3-25 angap-10 12:31am blood glucose-246* urean-54* creat-1.3* na-142 k-3.8 cl-109* hco3-25 angap-12 . endocrine: 04:07pm blood tsh-4.9* 04:07pm blood free t4-0.49* 02:52am blood cortsol-14.9 . micro: 4:15 pm blood culture **final report ** blood culture, routine (final ): proteus mirabilis. final sensitivities. enterococcus faecalis. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. sensitive to daptomycin (mic =0.19 mcg/ml). sensitivity testing performed by etest. dr. () requested sensitivities to ciprofloxacin and levofloxacin . sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | enterococcus faecalis | | ampicillin------------ <=2 s <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s =>8 r daptomycin------------ s gentamicin------------ <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s penicillin g---------- 4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s vancomycin------------ 1 s . 4:20 pm blood culture **final report ** blood culture, routine (final ): enterobacter cloacae. final sensitivities. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s anaerobic bottle gram stain (final ): gram negative rod(s). . 4:49 pm urine site: catheter **final report ** urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. escherichia coli. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ 4 s ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . 9:43 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia ,. 3:20 am immunology (cmv) source: line-aline. **final report ** cmv viral load (final ): cmv dna not detected. performed by pcr. detection range: 600 - 100,000 copies/ml. for research use only. not for use in diagnostic procedures. this test has been validated by the microbiology laboratory at . . imaging: cxr: impression: 1. stable cardiomegaly, with findings suggestive of chf. 2. bibasilar atelectasis with bilateral pleural effusions. . echo: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. physiologic mitral regurgitation is seen (within normal limits). there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. compared with the prior study (images reviewed) of , findings are similar. . cxr: findings: the new right cvp line tip is 1 cm above the cavoatrial junction. the ng tube passes below the diaphragm and out of view. bilateral small pleural effusions are stable since the chest radiograph earlier on today; however a slight increase in peribronchial cuffing and perihilar haziness is due to new mild pulmonary edema. impression: stable bilateral pleural effusions with new mild pulmonary edema. . ct chest impression: large bilateral pleural effusions with adjacent atelectasis. right middle lobe and probably left upper lobe pneumonic consolidation. cardiomegaly. large hiatal hernia. . ct head impression: there is no evidence of acute intracranial hemorrhage. left mastoid air cells opacities, possibly related with an ongoing inflammatory process, please correlate clinically. diffuse fat stranding is demonstrated in the soft tissues, likely related with the provided history of anasarca . eeg impression: as noted above, this is a technically unsatisfactory study due to physiologic artifact of prominent and persistent muscle artifact. although no evidence for non-convulsive status epilepticus was seen, the background was otherwise largely uninterpretable. . brief hospital course: this is an 83 year old woman with a history of pemphigus foliaceous and a recent icu admission for complex wound care, worsening skin sloughing, and hsv/cmv and pseudomonal skin superinfection who was admitted with altered mental status from polymicrobial sepsis and hypercapnic failure. she was intubated for apnea and co2 retention. a ct of chest showed rml pneumonia (antibiotics as below). bronchoscopy sowed edematous, collapsible airways. she was extubated on . her altered mental status was multifactorial due to sepsis and over-narcosis from dilaudid received during turning and maneuvering at nursing home. she was unable to tolerate lp due to body habitus, and mri was unobtainable due to patient girth. eeg was technically unsatisfactory, but did not reveal status epilepticus. when she got extubated, she was very weak in the setting of steroids and anasarca without any focal deficits. patient's mental status dramatically improved. in regards to her sepsis, blood cultures grew proteus mirabilis, enterococcus faecalis, and enterobacter cloacae and urine culture grew escherichia coli. she initially received vancomycin, meropenem, and levofloxacin. she came off pressors on after fluid and blood transfusions. on tte, there was no evidence of cardiogenic shock or tamponade (ef >75%), and serum cortisol was at normal range at 14.7. tte did not show vegetations. of note, she grew pansensitive klebsiella in the sputum which was felt to be a colonizer. she finished a full course of vancomycin and levofloxacin x total 14 days. the patient had clinical anasarca, and was on a lasix drip while in the icu and then metolazone and oral lasix. she developed significant contraction alkalosis (bicarb >50) at some point but this has resolved. she also had acute kidney failure on chronic kidney disease, stage 3. her renal function improved with lasix discontinuation. in regards to the pemphigus foliaceus, she had hsv/cmv superinfection during previous admission with cmv viremia. she had a skin biopsy that was consistent with disseminated hsv and was treated with acyclovir and then valacyclovir. skin lesions also grew pseudomonas and proteus which were felt to be colonizing and was treated with skin care including acetic acid only. ophthalmology was also consulted and they recommended erythromycin and ciprofloxacin eye drops for pseudomonas given she had skin lesions abutting her eyes. consult advised high dose oral steroids, continuing ganciclovir for cmv suppression, and monthly ivig. she received her first course of ivig which was complicated by mild hyponatremia. since then her skin condition remained stable. she should be seen by dr (immunobullous expert at ) to discuss any further ivig and taper steroids gradually. the prednisone should be tapered over four months otherwise she is at risk for relapse. the patient developed thrombocytopenia that worsened in the setting of sepsis and ganciclovir. pf4 ab was negative. ppi was changed to h2 blocker. platelets started to improve but she relapsed again. we could not stop ganciclovir as she is at risk for relapsed cmv/hsv infection. however, platelets have been stable at 70-80 without bleeding complications. there is no alternative for this medication per id. however, it could be stopped if she develops bleeding or severe thrombocytopenia (benefit/risk ratio changes). her metoprolol was held upon admission for sepsis and then for bradycardia. she had severe malnutrition and hypoalbuminemia. she initially received tube feeds (diabetic formulation) for poor po intake. speech and swallow evaluated the patient and started pureed solids and nectar thickened liquids. her tube feeds then were discontinued. she had severe hyperglycemia and frequent hypoglycemia from prednisone and further worsened in the setting of tube feeds. was consulted and adjusted her insulin (see printed ss)the patient was full code despite her chronic condition and acute illnesses. her hcp, daughter , refused dnr/dni and asked the patient remains in hospital despite resolution of acute medical problems. she was finally transfered to rehab after 2 family meetings 2 weeks apart. she will need follow up with both infectious disease (,) and (dr. , immunobullous expert at ). cmv viral load testing should be done every 2 weeks and next testing should be done with infectious disease appointment. cbc and chem 7 should be checked every 2-3 days. discontinue diuretics if she develops alkalosis or acute renal failure. please discontinue valganciclovir if severe thrombocytopenia or bleeding complications. she would need continuous wound care. foley catheter last changed on (genital skin lesions). i discssed her case with rehab m.d/np, , and id upon discharge. total discharge time 145 minutes. medications on admission: medications per d/c summary: discharge medications: 1. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) unit dose inhalation every four (4) hours as needed for shortness of breath. 6. atovaquone 750 mg/5 ml suspension sig: 1500 (1500) mg po daily (daily). 7. cholecalciferol (vitamin d3) 400 unit tablet sig: four (4) tablet po daily (daily). 8. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 9. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 10. hydrochlorothiazide 12.5 mg capsule sig: two (2) capsule po daily (daily). 11. furosemide 10 mg/ml solution sig: twenty (20) mg injection (2 times a day). 12. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 13. fondaparinux 2.5 mg/0.5 ml syringe sig: one (1) subcutaneous daily (daily). 14. hydromorphone 2 mg tablet sig: 1-2 mg po q3h (every 3 hours) as needed for pain. 15. hydromorphone in ns 2 mg/10 ml (0.2 mg/ml) syringe sig: 0.5 to 1 mg intravenous q2h (every 2 hours) as needed for for pain related to turning patient. 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 17. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 18. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, fever. 19. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation. 20. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 21. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed for dry skin. 22. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 23. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic qid (4 times a day). 24. acetic acid 0.25 % solution sig: one (1) appl irrigation (2 times a day) as needed for to affected area for dressing changes: use on areas with open blisters. 25. insulin fixed dose and sliding scale nph 20units subcutaneous qac breakfast and 10units qhs humalog sliding scale, check accucheck qac and qhs: breakfast, lunch, or dinner, for bs: <70 give 1 amp of d50 or juice 70-120 give 0 units 121-170 give 6 units 171-220 give 8 units 221-270 give 10 units 271-320 give 12 units 321-370 give 14 units >371 give 16 units and m.d. for qhs bloodsugars, if bs: <70 give 1 amp of d50 or juice 70-220 give 0 units 221-270 give 3 units 271-320 give 5 units 321-370 give 7 units >371 give 9 units and m.d. 26. prednisone 10 mg tablet sig: seven (7) tablet po daily (daily). 27. valganciclovir 450 mg tablet sig: one (1) tablet po bid (2 times a day): (through ). 28. metronidazole 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days: through . 29. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 30. calcium carbonate 500 mg/5 ml (1,250 mg/5 ml) suspension sig: one (1) po bid (2 times a day). 31. potassium & sodium phosphates 280-160-250 mg powder in packet sig: one (1) powder in packet po bid (2 times a day). 32. iv fluids iv ns @ 100cc/hr discharge medications: 1. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for sob/wheezing. 3. atovaquone 750 mg/5 ml suspension sig: one (1) po daily (daily). 4. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain/fever. 7. petrolatum ointment sig: one (1) topical tid (3 times a day) as needed for dry skin: petrolatum *nf* 1 application topical tid dry skin . 8. bacitracin-polymyxin b ointment sig: one (1) appl topical (2 times a day): bacitracin-polymyxin ointment 1 appl tp open areas . 9. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 10. cinacalcet 30 mg tablet sig: one (1) tablet po bid (2 times a day). 11. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 12. metolazone 5 mg tablet sig: two (2) tablet po bid (2 times a day). 13. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 14. valganciclovir 450 mg tablet sig: one (1) tablet po every other day (every other day): please stop if patient develops bleeding complications or severe thrombocytopenia. 15. prednisone 20 mg tablet sig: eighty (80) mg po daily (daily): this medication should be tapered slowly over 4 months period starting . 16. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 17. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 18. magnesium oxide 400 mg tablet sig: one (1) tablet po daily (daily). 19. multivitamin tablet sig: one (1) tablet po daily (daily). 20. insulin glargine 100 unit/ml solution sig: please see printed paper subcutaneous twice a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: mulitmicrobial sepsis pemphigus cmv/hsv skin infection pseudomonas skin colonization acute renal failure chronic kidney disease hyperglycemia with diabetes discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were treated for sepsis (blood infection) and skin infection. your penmphigus was treated with steroids and iv immunoglobulin. you may need monthly infusions of iv immunoglobulin if you and dr. agree. your will need to decrease your steroid dose very slowly over 4 months period. foley catheter has to be changed frequently to avoid infections. it was last changed on . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please call , s. for an appointment please follow up with dr. ,, m.d with infectious disease. please call to schedule an appointment in weeks for cmv viral load. you will have an appointment with dr. (an immunobullous expert at and women hospital ) with possible plans to continue ivig 5 days every month. dr. , will call you to provide you with the details of your appointment. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances arterial catheterization injection or infusion of immunoglobulin diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified anemia, unspecified unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hyposmolality and/or hyponatremia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified chronic kidney disease, stage iii (moderate) acute respiratory failure long-term (current) use of insulin septic shock morbid obesity pressure ulcer, lower back other septicemia due to gram-negative organisms other disorders of plasma protein metabolism streptococcal septicemia cytomegaloviral disease diverticulosis of colon (without mention of hemorrhage) herpes simplex without mention of complication chronic diastolic heart failure hypercalcemia colostomy status pressure ulcer, stage ii nutritional marasmus edema pemphigus 

Answer: The patient is high likely exposed to