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: the patient is a 55-year-old gentleman with a history of alcohol abuse and atrial fibrillation who was originally admitted to an outside hospital for a open reduction/internal fixation of his right patella which he had fractured back in but was never repaired since the patient went into a delirium tremens secondary to alcohol withdrawal requiring intubation and subsequently developing aspiration pneumonia, a stage ii decubital ulcerations, a gout flare, acute renal failure (thought to be possibly secondary to post streptococcal glomerulonephritis secondary to streptococcal sepsis), and hepatic failure with encephalopathy. the patient was initially admitted to the intensive care unit here on . during his intensive care unit course, he recovered his renal and liver function. he had a waxing and mental status which was subsequently attributed to first to hepatic encephalopathy; as lumbar punctures were done which were negative, and an electroencephalogram was consistent with a metabolic encephalopathy. also during this hospital medical intensive care unit course, the patient was briefly intubated secondary to a hypoventilatory pattern which eventually self corrected; the etiology of which was uncertain. the patient also had hyponatremia which improved with free water boluses, a left lower lobe pneumonia with gram-positive cocci in the sputum (which was treated with vancomycin initially which was discontinued secondary to a rash that was thought to be secondary to linezolid), and continued difficulty with atrial fibrillation while holding anticoagulation because of a possible decreased hematocrit although no obvious bleed was ever located, and also transient hypertension requiring labetalol. the medical intensive care unit course was also complicated by hypothyroidism and coagulase-negative staphylococcal bacteremia (which was treated with a 14-day course of linezolid). the patient was initially transferred from the intensive care unit to the floor on . the patient had been stable in terms of his hemodynamics and his respiratory status with minimal oxygen support, and his waxing and mental status which was initially attributed to toxic/infectious etiology had been improving. however, the patient was still noted to have fevers and also found to be tremulous. on the floor, his peripherally inserted central catheter line was discontinued, and the tip was sent for cultures as well as blood cultures being sent on . it was felt that possibly his peripherally inserted central catheter line was the source of his fevers. both cultures ended up being negative to date. his fever curb had been improving, and his synthroid was discontinued initially for his hypothyroidism. however, the patient had a magnetic resonance imaging showing increased diffuse white matter hyperintensity suggesting ischemia versus ongoing inflammation process versus a leukoencephalopathy. meanwhile, the patient had received several units of packed red blood cells for an anemia and had been consulted by infectious disease for these persistent fevers which were initially thought to be possibly secondary to his known coagulase-negative staphylococcal bacteremia. the patient was continued on linezolid while fungal cultures were sent. this was going on while on the floor, and the patient actually began to eat on . however, on the evening of and , the patient became increasingly hypoxemic with a low oxygen saturations on room air; down to 85% which improved to 90s on 2 liters with an arterial blood gas showing a ph of 7.42, a carbonate dioxide of 51, and an oxygen of 48, on 96% on 4 liters. the patient had also spiked at this point to 101.5 and had increased tremulousness. he also had a decreased mental status. repeat blood gases on 4 liters nonrebreather showed an arterial blood gas of 7.43/49/68, but the patient had a lactate of 3.8. the patient was then transferred to the intensive care unit for a subsequent evaluation of his decreased mental status and his persistent hypoxia. at this point, a discharge summary will be added by the intensive care unit team who cared for him from the period of until . the dictation will resume at this point on . from a respiratory standpoint in the intensive care unit, the patient had come in with increased hypoxemia. he had experienced chronic hypoxia which had actually been managed on a face mask since last nasal cannula in the intensive care unit. it was presumed during the intensive care unit stay that the patient had an aspiration event. the patient was initially treated empirically with clindamycin and linezolid. the clindamycin was discontinued after a 5-day course, and the patient was nearing the completion of his 14-day course of linezolid by the time of being discharged from the unit. also from a respiratory standpoint, the patient had pleural effusions that were identified as transudative in nature by a thoracentesis under radiographic assistance with both negative cultures and gram stains. the patient had been briefly intubated on during his intensive care unit stay for an elective transesophageal echocardiogram and magnetic resonance imaging and was extubated on without any complications. the patient was able to maintain his oxygen saturations on nasal cannula; although, arterial blood gases during the intensive care unit stay showed persistent hypercarbia of unclear etiology. it was possibly thought that he had an obstructive sleep apnea which could possibly be worked up at a later time. from a neurologic standpoint, the patient had experienced encephalopathy and waxing and mental status; for which neurology had been consulted (as previously mentioned earlier). the patient had a repeat magnetic resonance imaging which showed metabolic/toxic encephalopathy that improved over the last several days. the magnetic resonance imaging on showed improved diffuse white matter changes when compared with the previous examination earlier at the end of ; which was consistent with resolving encephalopathy. as mentioned above, the patient's mental status had improved clinically; although, mental status was still waxing and at times. from an infectious disease standpoint, the patient had last spiked fevers on to 102 degrees fahrenheit. at the time of transfer to the floor, the patient had been completing a 14-day course of linezolid for coagulase-negative staphylococcal bacteremia. upon admission to the intensive care unit, his second time around, the patient had been started on clindamycin and linezolid for a presumed aspiration pneumonia. the clindamycin was discontinued after five days. meanwhile, the patient had urine cultures from and . they were positive for pseudomonas. he was initially started on ciprofloxacin and gentamicin with the pseudomonas resistant to both these, so it was changed to ceftazidime for several days; which was discontinued on , per infectious disease recommendations. meanwhile, the patient had been maintained on linezolid for a 14-day course. he had a urine cultures on which was positive for pseudomonas; however, a repeat urine culture from was negative. meanwhile, the patient had a transesophageal echocardiogram on which was negative for any endocarditis. he underwent a thoracentesis from the pleural space and a paracentesis under ultrasound-guidance assistance. all of these cultures were negative for growth to date. the patient did spike to 102 degrees fahrenheit; most recently on and . the patient was afebrile since the period leading to his time on the floor with a stable white blood cell count. from a cardiovascular standpoint, the patient had an echocardiogram (as mentioned above) and had atrial fibrillation which had been reasonably well rate controlled with diltiazem and metoprolol without anticoagulation secondary to concerns about possible bleeding. initially, it was felt that possibly the patient had a component of heart failure that was causing his hypoxia. the patient had been given some lasix. from a gastrointestinal standpoint, the patient had been on tube feeds but had now been changed to soft solids which he had been tolerating very well. he had passed a swallowing study earlier during his hospital course. his liver function tests remained stable. as mentioned above, his abdominal ultrasound and paracentesis showed a fatty liver and sludging of the gallbladder. the peritoneal fluid was no growth to date. meanwhile, from a hematologic standpoint, the patient had received transfusions. his hematocrit remained stable as did his renal function. the patient was still with a metabolic alkalosis of unclear etiology. past medical history: his past medical history (as summarized in the previous dictation summaries) was: 1. alcohol abuse. 2. atrial fibrillation. 3. decubitus ulcerations. 4. acute renal failure; resolved. 5. hypertension. 6. depression. 7. lipids. 8. status post right patellar fracture. allergies: his allergies included vancomycin (which was presumed to be causing a rash). medications on transfer: (his medications on transfer included) 1. metoprolol 75 mg by mouth three times per day. 2. linezolid 600 mg by mouth q.12h. 3. diltiazem 60 mg by mouth three times per day. 4. captopril 6.25 mg by mouth three times per day. 5. subcutaneous heparin twice per day. 6. albuterol and ipratropium inhalers. 7. ursodiol 300 mg by mouth twice per day. 8. folate 1 mg by mouth once per day. 9. thiamine 100 mg by mouth once per day. 10. lansoprazole 30 mg by mouth once per day. physical examination on transfer: on transfer, his vital signs revealed his temperature was 99.4 degrees fahrenheit, his blood pressure was 120/70, his heart rate was in the 60s, his respiratory rate was 18, and his oxygen saturation was 96% on 2 liters. in general, he was awake and alert. he was following commands. he was oriented to year and hospital. his head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. extraocular movements were intact. pupils were equal, round, and reactive to light and accommodation. mildly scleral icterus. his mucous membranes were moist. the oropharynx was clear. carotids were 2+. no bruits. no lymphadenopathy. cardiovascular examination revealed a irregularly irregular with a 2/6 systolic ejection murmur at the left sternal border. pulmonary examination revealed diffuse bilateral crackles about a quarter of the way up the bases. abdominal examination revealed multiple ecchymoses. rectal examination with brown stool and mildly protuberant. positive bowel sounds. soft, nontender, and nondistended. his extremity examination revealed multiple circular nodules soft in consistency, nonerythematous and nontender, which were seen below his left patellar on his left radial styloid process and the digits of his upper extremities and lower extremities. his cranial nerve examination revealed cranial nerves ii through xii were grossly intact. he followed commands. he did not have any asterixis. pertinent laboratory values on transfer: his complete blood count on transfer revealed his white blood cell count was 9.6, his hematocrit was 32.7, and his platelet count was 180. his coagulations revealed a prothrombin time of 14.1, his partial thromboplastin time was 29.1, and his inr was 1.3. his chemistries revealed sodium was 138, potassium was 3.6, chloride was 92, bicarbonate was 37, blood urea nitrogen was 9, creatinine was 0.5, and his blood glucose was 82. his calcium was 8.1, his magnesium was 1.4, and his phosphorous was 2.3. his liver function tests revealed ast was 46, alt was 22, lactate dehydrogenase was 238, alkaline phosphatase was 205, and total bilirubin was 4. his urinalysis showed specific gravity of 1018, small amounts of blood, bilirubin, 3 to 5 red blood cells, and several white blood cells. his urine cultures from were negative. urine cultures from and revealed pseudomonas. his blood cultures from , , and were negative. his stool cultures revealed he was clostridium difficile negative times three. his peritoneal cultures from were negative. his pleural cultures from were negative. pertinent radiology/imaging: he had a transesophageal echocardiogram on which showed patent foramen ovale, dilated right atrium, left ventricular ejection fraction of 55% or greater, with moderate mitral regurgitation. no evidence of an vegetations. concise summary of hospital course by issue/system: (on arrival to the floor) 1. neurologic issues: from a neurologic standpoint, the patient had a waxing and mental status that had been worked up previously by neurology (as mentioned in previous dictation summaries). it was thought most likely that the patient's mental status changes were secondary to a metabolic-type picture. during his stay on the wards, and the remainder of his hospital course, his mental status did continue to wax and wane; tending to wane during periods of fevers but then improving when treated supportively. currently, he has been oriented to hospital and time. no other treatment has been necessary from this standpoint. 2. cardiovascular issues: from a cardiovascular standpoint, the patient came in with a diagnosis of atrial fibrillation during his intensive care unit course. there had been reports of the patient having difficulty with rate control and hypertension. however, while the patient was on the floor, following his second medical intensive care unit stay, the patient had achieved excellent rate control on his diltiazem and metoprolol with heart rates in the 80s and 90s. he was hemodynamically stable as well. anticoagulation has been an issue for the patient. as of now, he has not been anticoagulated; but rather on aspirin. initially, there was question of whether or not the patient would possibly be going to the operating room for repair of his right patellar fracture and there was concern about anticoagulating the patient prior to surgery. however, now that the patient will not be going to the operating room until a later date, it was likely that the patient will begin to be anticoagulated; to begin with coumadin. an addendum will be added to this discharge summary as to whether or not the patient will be anticoagulated; just making sure that the patient is not a fall risk; given that at times his waxing and mental status. otherwise, in preparation for possible surgery, the patient underwent a persantine mibi on which essentially was negative for any possible ischemic changes. there was concern about the previous echocardiograms. the patient had experienced mildly depressed right ventricular function with a dilated right ventricle and occasional reports of some mild systolic function from the left ventricle. the last report showed an ejection fraction of about 55%. there was concern that this right ventricular dilation/dysfunction might be secondary to a pulmonary embolism. as such, a computed tomography angiogram was done on which essentially was negative for a pulmonary embolism. the patient was to be maintained on his ace inhibitor which will be transferred over from captopril to a once per day dosing of lisinopril. otherwise, there were no other cardiovascular issues. 3. pulmonary issues: from a pulmonary standpoint, the patient had come from the intensive care unit with this persistent hypoxia and increased hypercarbia. the etiology was unclear of his hypercarbia. it was postulated during the intensive care unit course that the patient may have had some type of obstructive sleep apnea. also, a possibility that the patient had some type of metabolic alkalosis that was contributing to his hypercarbia/hypoxia. on the floor, after his second discharge from the intensive care unit, the patient maintained his oxygen saturations reasonably well on 1 liters to 2 liters of nasal cannula. at the time of discharge, the patient was saturating well on room air. it was felt that the patient may have had a mild component of heart failure. as such, the patient was mildly diuresed. in addition, it was thought possibly that the patient may have had some underlying atelectasis from his prolonged immobility and would probably would benefit from incentive spirometry. meanwhile, as mentioned above, the patient did have an additional computed tomography angiogram performed on which essentially was negative for a pulmonary embolism and did show some bilateral pleural effusions and atelectasis. in addition, it showed some mediastinal lymphadenopathy 11 mm in its largest dimension. these nodes were also located in the paratracheal region and the subcarinal region. this was not worked up at this point. otherwise, as mentioned above, despite his past episodes of hypoxia and intubations, the patient has been stable from this standpoint. 4. gastrointestinal issues: from a gastrointestinal standpoint, the patient had initially been admitted with a component of hepatic failure of unclear etiology; whether it was alcoholic or drug induced. after his second intensive care unit stay, the patient's liver function tests remained fairly stable with the exception of a mildly elevated bilirubin which has not shown significant changes or fluctuations. the patient has been alert in terms of mental status. he has taken by mouth. he was to be maintained on a protonix for gastrointestinal prophylaxis. 5. hematologic issues: from a hematologic standpoint, the patient's hematocrit remained stable during the remainder of his hospital course on the general medicine . he was not anticoagulated initially secondary to a question about whether the patient would be going to the operating room for repair of his patellar fracture. the patient was maintained on aspirin and deep venous thrombosis prophylaxis. pending discussions with physical therapy and after judging the patient's risk for fall, the patient may be restarted on anticoagulation with coumadin. 6. infectious disease issues: the patient had a very complicated infectious disease course with a history of recurrent fevers during his hospital course even after his second medical intensive care unit course. initially when the patient came back to the floor, the patient had a history of a recent urinary tract infection with pseudomonas with cultures from , but negative on . at the time of arrival to the floor, the patient was completing his 14-day course of linezolid which subsequently was discontinued. however, on the morning of , the patient had spiked a fever to 101.5 degrees fahrenheit with decreased mental status. blood cultures and urine cultures were sent which ended up growing out pseudomonas, and the patient was restarted on a 7-day course of ceftazidime, of which he ended up completing. repeat urine cultures from showed essentially less than 10,000 organisms. it was felt reasonably that the patient could be discontinued from any further antibiotics. blood cultures from these areas were also negative to date. infectious disease service was consulted for this, and they recommended continuing on the ceftazidime (as mentioned above) and culturing for temperatures of greater than 100.4. meanwhile, at the time of the development of these fevers, the patient also had new extremity nodules; most prominent on his left knee and left wrist and fingers which were new from during his earlier hospital course. there was concern about whether or not these nodules could be in fact related to his possible fevers. as such, two of these nodules (one from the left knee and one from the left wrist) were drained. cultures and gram stains from this fluid were negative for any organisms; although, they did show significant amounts of white blood cells. ultimately, they were just believed/presumed to be secondary to gout, as they were confirmed to have sodium urate crystals on the microscopy. rheumatology was consulted for this, and this will be addressed later on during this discharge summary. the patient also had clostridium difficile toxin which was negative. 7. renal issues: from a renal standpoint, the patient had come in initially with renal failure during his first stay in the intensive care unit. during the remainder of his hospital course, after his second transfer from the intensive care unit, his electrolytes remained stable. he had previously had a metabolic alkalosis of unclear etiology which was concerning given the fact that he had a very tenuous respiratory status; as evidenced by two prior intubations for hypercarbic arrest. his electrolytes were just followed during the remainder of his hospital course, and they gradually improved on their own. his renal function was stable as well. meanwhile, the patient had his foley catheter discontinued and was urinating on his own. there was a persistent hypomagnesemia of undetermined etiology. the patient will have to be discharged with standing doses of magnesium oxide to replete this constant electrolyte disorder. 8. endocrine issues: as mentioned above, the patient had the onset of development of these new multiple soft nodules throughout his extremities; most prominent on his left and left wrist, but also on the fingers of his left and right upper extremities. given his history of gout, there was concern about whether this could be a new gout flare which could possibly be causing fevers. as mentioned above, these nodules were nontender, and for the most part nonerythematous or warm with the exception of one nodule on his knee. these nodules were drained on and showed over 20,000 to 30,000 white blood cells. as mentioned above, the gram stain was negative and the cultures were all negative. however, they did show sodium urate crystals consistent with gout. rheumatology was consulted for further assistance in this matter, and they seemed to think that this was tophaceous acute-on-chronic gout. they recommended starting colchicine which the patient is now on and later possibly switching to a anti-hyperuricemic such as allopurinol at a later date. the patient was scheduled for a follow-up appointment with rheumatology on at 9 o'clock in the morning. 9. musculoskeletal issues: finally, but most importantly, from a musculoskeletal standpoint, the patient was initially admitted back in at an outside hospital and later in at for possible repair of a right patellar fracture. however, this was not able to be repaired secondary to his very complicated medical course. it was initially hoped that the patient would undergo surgical intervention when medically stable; which he was felt to be by his primary team. the patient had follow-up x-rays on which showed a widely separated patellar fracture and a possible medial fracture on the right side. orthopaedics has evaluated the patient, and thought at this point that the patient could be discharged with physical therapy with a knee immobilizer and full weightbearing with possibly followup with dr. at the patient's own discretion for ultimate repair of this right patellar fracture. the patient will need physical therapy, and at this point is believed to weightbearing as tolerated. discharge diagnoses: 1. right patellar fracture. 2. hepatic/renal failure; resolving. 3. metabolic/toxic encephalopathy; resolved. 4. hypercarbic respiratory arrest; now stable. 5. acute-on-chronic tophaceous gout; improving. 6. coagulase-negative staphylococcal bacteremia; resolved. 7. urinary tract infections with pseudomonas; now resolved. condition at discharge: his condition on discharge right now is improving. medications on discharge: (the patient's medications on discharge were to include the following) 1. lisinopril 10 mg by mouth once per day. 2. diltiazem-xr 240 mg by mouth once per day. 3. heparin 5000 units subcutaneously q.12h. 4. colchicine 0.6 mg by mouth once per day. 5. ursodiol 300 mg by mouth twice per day. 6. folate 1 mg by mouth once per day. 7. thiamine 100 mg by mouth once per day 8. protonix 40 mg by mouth once per day. 9. albuterol nebulizer solution one q.2h. as needed. 10. atrovent nebulizer q.4-6h. as needed. 11. metoprolol 75 mg by mouth three times per day. 12. magnesium oxide 800 mg by mouth twice per day. note: the remainder of his discharge summary will be added in an addendum in terms of his ultimate destination for acute rehabilitation. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung insertion of endotracheal tube insertion of endotracheal tube thoracentesis percutaneous abdominal drainage arthrocentesis injection or infusion of oxazolidinone class of antibiotics diagnoses: urinary tract infection, site not specified alcoholic cirrhosis of liver acute kidney failure, unspecified atrial fibrillation pneumonitis due to inhalation of food or vomitus other sequelae of chronic liver disease pseudomonas infection in conditions classified elsewhere and of unspecified site alcohol withdrawal delirium other staphylococcal septicemia 

Answer: The patient is high likely exposed to