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: zantac 75 attending: chief complaint: fevers, further medical management of recurrent diverticulitis major surgical or invasive procedure: placement of central venous catheter endotracheal intubation placement of central venous catheter history of present illness: ms. is a 48 year old female who was transferred to on via ambulance from an osh. she has a history or recurrent diverticulitis and underwent a total colectomy with an ileorectal anastomosis on . post-operatively she developed an anastomotic leak and underwent a takedown of the ileorectal anastomosis, pouch, and recreation of the ileostomy on . post-operatively she remained intubated; on she had brown purulent material expressed from her abdominal wound with cultures growing gram positive cocci and pseudomonas; blood cultures were negative; sputum cultures demonstrated methicillin resistant staphylococus aureus. she had a temperature spike of 106 and required pressure support, she was transferred to for further management and admitted to the surgical intensive care unit. past medical history: past medical history: diverticulitis anxiety past surgical history: exploratory laparotomy with total colectomy takedown of ileorectal anastomosis, pouch, ileostomy ' sigmoid colectomy social history: married family history: non-contributory physical exam: on admission: 99.2 105 107/78 33 100% simv (600 x 12) gen: intubated, sedated, has nasogastric tube heart: regular rate and rhythm lungs: difficult to assess abd: ostomy with dark brown output, open midline wound with retention sutures ext: pulses present pertinent results: admission labs: 09:45pm blood wbc-12.5* rbc-2.86* hgb-8.9* hct-25.3* mcv-89 mch-31.0 mchc-35.0 rdw-15.2 plt ct-429 09:45pm blood neuts-87.2* lymphs-8.3* monos-3.2 eos-1.1 baso-0.2 09:45pm blood pt-13.8* ptt-26.6 inr(pt)-1.2* 09:45pm blood ret aut-1.5 09:45pm blood glucose-102 urean-31* creat-0.5 na-145 k-3.2* cl-111* hco3-24 angap-13 09:45pm blood alt-42* ast-43* ld(ldh)-224 alkphos-278* amylase-69 totbili-0.8 09:45pm blood lipase-56 09:45pm blood albumin-2.6* calcium-8.0* phos-2.8 mg-2.2 10:13pm blood freeca-1.20 9:49 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. smear reviewed; results confirmed. 5:50 pm urine urine culture (final ): no growth. discharge labs: respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. moderate growth. of two colonial morphologies. yeast. sparse growth. 4:09 pm blood culture aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. 1:52 pm bronchoalveolar lavage gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): sparse growth oropharyngeal flora. staph aureus coag +. moderate growth. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. _________________________________________________________ staph aureus coag + | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s fungal culture (preliminary): no fungus isolated. discharge labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 04:01am 8.7 3.34* 10.1* 28.8* 86 30.4 35.2* 14.7 294 renal & glucose glucose urean creat na k cl hco3 angap 04:01am 109* 20 0.6 138 4.3 100 30 12 ct pelvis w/o contrast 9:43 pm ct abdomen w/o contrast; ct pelvis w/o contrast reason: eval anastomotic leak s/p colectomy field of view: 40 medical condition: 48f s/p anastomotic leak following colectomy reason for this examination: gastrografin contrast to eval for leak, ?abscess- please no iv contrast- patient has renal problems contraindications for iv contrast: renal indications: 48-year-old woman with history of anastomotic leak status post colectomy. evaluate for leak. technique: axial non-contrast ct imaging of the abdomen and pelvis was obtained. at the request of the referring physicians, intravenous contrast was not administered because of renal insufficiency, and gastrografin was administered as oral contrast. ct of the abdomen without iv contrast: a nasogastric tube terminates in the stomach. there is discoid atelectasis in the lingula and left lower lobe. otherwise, the lung bases are clear without effusions. the liver appears normal. the patient is status post cholecystectomy. the spleen, adrenal glands, pancreas, and kidneys are unremarkable. the stomach and proximal small bowel are within normal limits. this patient is status post colostomy and hartmann's pouch. the bowel is not dilated, and there is no evidence of obstruction. contrast passes into the ileostomy. the is a site of narrowing in the distal small bowel, which may be due to underdistention, although stricture or post- operative edema at an anastamotic site cannot be excluded. there is a large amount of fat stranding in the right retroperitoneum near the ileostomy site. in addition, there is a hazy appearance of peripheral intra- abdominal fat, which extends down into the left pelvis, within the the left paracolic gutter. in the mid lateral left abdomen, there are some densites which may represent extraluminal inspissated contrast related to the history or prior bowel leak. there is no free air, ascites, or lymphadenopathy. there is no evidence of free leakage of contrast. ct of the pelvis with iv contrast: the uterus is present. anastomotic suture lines are seen associated with the hartmann's pouch. there is no lymphadenopathy or free fluid. bone windows: there are no suspicious lytic or blastic lesions. there is a sclerotic focus in the left proximal femur, a probable bone island. impression: 1. status post ileostomy without evidence of obstruction or free leakage of contrast. 2. extensive inflammatory change in the right retroperitoneal fat and left paracolic gutter. this appearance is non-specific but may all reflect recent post-operative change. date: oropharyngeal videofluoroscopic swallowing evaluation evaluation: an oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with radiology. thin liquid, nectar-thick liquid, pureed consistency barium, one quarter ground cookie coated with barium and one half cookie were administered. results follow: oral phase: bolus formation was mildly reduced with mildly prolonged mastication of the cookie. bolus control was also mildly reduced with her head in the upright position with premature spillover to the valleculae. ap tongue movement was mildly reduced with mild tongue weakness, although noted to be significantly improved from the last evaluation. oral transit time was wfl for liquids and purees and mildly prolonged with the cookie. there was a trace coating of oral residue that was cleared with repeat swallows. pharyngeal phase: swallow initiation was timely with adequate palatal elevation. laryngeal elevation and laryngeal valve closure were both mildly reduced. epiglottic deflection was only present with larger, heavier boluses with her head upright, but deflection was seen ith all consistencies when using the chin tuck. she had a moderate amount of residue in the vallecular after purees and solids with her head upright that was significantly reduced to a trace to mild amount with the chin tuck. repeat swallows cleared the remaining residue. no significant residue was seen in the pyriform sinuses. aspiration/penetration: the pt had trace to mild penetration during the swallow with the thin liquids reduced laryngeal valve closure and spillover. while the chin tuck reduced the penetration and no aspiration was seen on today's evaluation, there is concerned for fatigue over the course of a meal which could result in increased premature spillover and/or increased pharyngeal residue which could result in aspiration. treatment techniques: the chin tuck reduced the amount of penetration and residue in the valleculae and increased oral control and laryngeal valve closure / epiglottic deflection. using and effortful swallow with the chin tuck further reduced the amount of residue in the valleculae as did taking repeat swallows using the chin tuck and alternating between consistencies. summary: the pt presented with a mild oral and pharyngeal dysphagia with significant improvement from the previous evaluation. she has reduced oral control and mild oral weakness resulting in premature spillover that can be eliminated with the use of a chin tuck. pharyngeal residue seen in the valleculae is reduced by using a chin tuck and effortful swallow for liquids and solids, taking a repeat swallow with a chin tuck and alternating between bites and sips. while she did not aspirate today, there is concern for aspiration of thin liquids over the course of a meal secondary to fatigue which could result in decreased oral control and / or increased pharyngeal residue. for now, the recommendation is for a po diet of nectar thick liquids and ground consistency solids using the above strategies. recommendations: 1. suggest a po diet of nectar thick liquids and ground consistency solids. 2. when swallowing: a) tuck your chin to your chest for liquids and solids b) swallow "hard" c) take a second, dry swallow for each bite and sip with her chin tucked. d) alternate between every bite and sip 3) please crush all pills and give with purees, following the above strategies 4. speech therapy at rehab for her dysphagia to continue swallowing therapy and to safely advance her diet as tolerated these recommendations were shared with the patient, the nurse and the medical team. ___________________________________ , m.s., ccc-slp pager # pgy-3 psychiatry consultation followup s: met with patient and husband for supportive contact. the patient was taken down for a video swallowing eval today, which she passed, and she is now able to eat netcar think liquids and ground solids. when i arrived, two empty trays of food were next to the patient. she reports that she is so relieved to finally be able to eat, and that overall she is feeling much better. she also has been up and moving around with the help of pt. she reporrts that her back has been quite sore, is a little disappointed by how tired she continues to be, though she understands that things will be difficult as she has been lying in bed for almost 6 weeks now. she does report ongoing struggles with anxiety, though feels as if the medications are appropriate for now. she also says that she is having some difficulty sleeping, but she is trying to get increased activity during the day in order so that she will be more tired at night. impression: 48 year old woman with a history of sigmoid diverticulitis, sigmoid colectomy, admitted to an osh for abdeominal pain, now s/p total colectomy, recreation of ileostomy after ileorectal anastomosis leaking. her course has also been compicated by a mrsa aspiration pneumonia. she had been quite frustrated earlier in the week due to being npo, but passed a video swallow test today, and is feeling better now that she has some control over her eating. 1. recommend continuing ativan 0.5 mg po q4-6h prn. 2. would continue lexapro 20 mg po qday. 3. if continued difficulty sleeping, could increase trazodone to 100 mg qhs. 6. at night and on weekends, plase page x. abdomen (supine & erect) 8:44 am reason: rule out small bowel obstruction medical condition: 48 year old woman with diverticulitis, s/p total colectomy and ileostomy c/b intubation x 2 and icu admissions, diet advanced, now with nausea & vomiting reason for this examination: rule out small bowel obstruction indication: 48-year-old woman with history of diverticulitis, status post total colectomy and ileostomy. now with nausea and vomiting. comparison: abdominal and pelvic ct, . two views of the abdomen. no evidence of free air under the hemidiaphragms. nonspecific bowel gas pattern is seen with several air-fluid levels on the upright view, as well as small amount of gas noted within the small bowel. no distended loops of small bowel are seen. surgical clips noted in the right upper quadrant and small amount of retained contrast noted in the region of the rectum. impression: nonspecific bowel gas pattern with several air-fluid levels and small amount of gas noted within the small bowel. no distended loops of small bowel identified. 7:02 am swab site: abdomen source: abdominal wound. gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative rod(s). wound culture (pending): anaerobic culture (pending): 8:53 am urine **final report ** urine culture (final ): no growth. brief hospital course: upon admission to the surgical service and intensive care unit she remained intubated and sedated. vancomycin, zosyn, and fluconazole were initiated for coverage of the pseudomonas and gram positive cocci in her wound and mrsa in sputum. she was afebrile and did not require pressure support. on hd 2 a dobbhoff was placed and tube feeds were initiated. on hd 5 she was extubated without difficulty. a wound vacuum assisted device was placed secondary to purulent drainage with removal of her retention sutures. she completed treatment of the fluconazole on hd 6 and the vancomycin and zosyn were completed on hd 7. she was transferred from the surgical intensive care unit to an in-patient nursing unit on hd 8. on hd 9 she underwent a oropharyngeal swallow study and was found to be at a high risk for aspiration, she was maintained nothing by mouth and tube feeds continued. on hd 10 she was febrile and developed respiratory distress. she was intubated, mechanically ventilated and transferred back to the surgical intensive care unit. a ct of the chest was negative for a pulmonary emboli and ct of the abdomen was negative for obstruction or leak, her abdominal wound was stable and she continued with the vacuum assisted closure device. she had a work-up for her septic episode and was started on vancomycin and zosyn along with intravenous hydration. her blood and urine cultures drawn at the time of her febrile episode were negative for bacteria. she was successfully extubated on hd 12 and transferred back to an in-patient nursing unit on hd 14. the zosyn was discontinued after three days of therapy and the vancomycin was continued after final cultures of her sputum demonstrated methicillin resistant staphylococcus aureus. on hd 15 the surgical team felt she would benefit from a psychiatry consult since she was expressing frustrations over prolonged hospitalization. it was recommended to continue the ativan as needed for anxiety and her lexapro for a past history of depression and providing trazodone at bedtime for sleep aid. her biggest concern was the ability to eat and swallow. consult was placed on hd 16 for further evaluation of her elevated blood glucose, she had been on an insulin sliding scale since admission to the hospital. per recommendation she was placed on lantus. on hd 18 she underwent a repeat swallow study with improvement, her diet was advanced to pureed solids with nectar thick liquids. her lantus was discontinued as recommendation and she was maintained on a regular insulin sliding scale. felt that her insulin requirements would change based on her oral intake and that she would benefit from follow-up with her primary care provider in one to two weeks to evaluate her glucose levels and amounts of insulin taken from the sliding scale. on hd 19 her diet was advanced to a soft, dysphagia diet which she tolerated well. she remained afebrile, her ileostomy was functioning well and had increased ambulation with the help of physical therapy. her abdominal continued to improve with dressing changes every three days. the vacuum assisted device dressing was changed every three days, on hd 19 the abdominal wound was noted to be 3cm by 7cm with good healing of pink/red tissue, granulating well, no debridement was necessary. on hd 21 the wound vac was discontinued and normal saline wet to dry dressing changes were started, twice a day. her pain was well controlled with percocet. on hd 22 she had nausea with an episode of emesis, an abdominal x-ray was negative for a small bowel obstruction, her nausea improved with the advancement of her diet to include ensure pudding supplements which she tolerated well. she completed 14 days of vancomycin on hd 24 and her central venous line was removed. on hd 25 her wound had cream colored drainage with a foul smell, a culture was done which demonstrated gram negative rods, probable pseudomonas. the dressing changes were changed from normal saline to ascetic acid 0.25% wet to dry twice a day. there was no need to treat with antibiotics since the infection was localized to the wound, she was afebrile, and the wound was without erythema or induration. a nystatin oral regimen was initiated on hd 25 for mild thrush in her mouth. she had two falls while ambulating to the bathroom on hd 25 and 26. the first fall she was ambulating without assistance, the second she was being assisted to the shower. she had no injuries from either fall, she reported feeling weak and light-headed after reaching the bathroom. she was provided a gait belt during ambulation and will need assistance at all times with ambulation. she was instructed to change her positions slowly and oral intake was encouraged throughout the day. she was also given a mulitpodous boot to her left leg after complaints of cramping in her foot during the night, her symptoms have improved with the boot. upon discharge her blood glucose levels were stable from 110-130, her finger sticks with a regular insulin sliding scale were decreased to twice a day, she will follow-up with her pcp upon discharge from rehab. for further management of her insulin requirements. she was discharged to facility in good condition on for continued physical, occupation, speech, and swallow therapy. medications on admission: anacordol lopressor 5mg q4 hr fentanyl 100mcg nocuron morphine protonix zosyn mycostatin subcutaneous heparin vancomycin fluconazole discharge medications: 1. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day) as needed: apply to affected areas. 2. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed: apply to affected areas. 3. nicotine 7 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 4. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily): must be crushed and placed in pureed food. 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain: must be crushed and placed in pureed food. 6. lorazepam 0.5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed: must be crushed and placed in pureed food. 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): continue until patient ambulatory. 8. other sig: insulin sliding scale twice a day: , i insulin sc (per insulin flowsheet) sliding scale fingerstick bidinsulin sc sliding scale regular insulin dose 0-60 mg/dl amp d50 61-120 mg/dl 0 units 121-140 mg/dl 3 units 141-160 mg/dl 6 units 161-180mg/dl 9 units 181-200 mg/dl 12 units 201-220 mg/dl 15 units 221-240 mg/dl 18 units 241-260 mg/dl 21 units 261-280 mg/dl 24 units 281-300 mg/dl 27 units > 300 mg/dl notify m.d. . 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day): hold for hr < 60 hold for sbp < 100 please crush and place in applesauce. 10. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily): please give mixed in applesauce. 11. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime): please crush pill and place in apple sauce. 12. nystatin 100,000 unit/ml suspension sig: five (5) ml po every 4-6 hours. 13. acetic acid 0.25 % solution sig: one (1) appl irrigation (2 times a day): for wound dressing changes . discharge disposition: extended care facility: - discharge diagnosis: diverticulitis aspiration pneumonia psuedomonal wound infection discharge condition: good discharge instructions: notify md/np/pa/rn at rehabilitation facility if you experience: *increased or persistent pain *fever > 101.5 *nausea or vomiting *difficulty swallowing *inability to pass gas or stool from ileostomy *difficulty swallowing or shortness of breath *if wound develops increased erythema, drainage, or induration *any other symptoms concerning to you followup instructions: follow-up with dr. in weeks, call for an appointment. follow-up with your primary care provider . in 2 weeks, call for an appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus other immobilization, pressure, and attention to wound diagnoses: anemia, unspecified other postoperative infection cellulitis and abscess of trunk diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled infection with microorganisms resistant to penicillins candidiasis of mouth acute respiratory failure pneumonitis due to inhalation of food or vomitus long-term (current) use of insulin methicillin susceptible pneumonia due to staphylococcus aureus pseudomonas infection in conditions classified elsewhere and of unspecified site candidiasis of skin and nails attention to ileostomy pain in limb 

Answer: The patient is high likely exposed to