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: zosyn attending: chief complaint: fever, hypoxia, hypotension major surgical or invasive procedure: 1. tracheostomy 2. picc line 3. mechanical ventilation/intubation history of present illness: yo f with h/o dementia, cva with residual left sided paralysis who presents from a nh with fevers and hypoxia. per nh records and family report, pt was found to be febrile to 103f, hypoxic to 88% on ra today and was noted to have a cough. daughter believes that pt has been "sick" for at least a week as she has been less conversant and responsive. she has also noticed shallow, rapid breathing that occasionally improves after neb treatments. a cxr was reportedly done at the nh on monday that was negative. however, she had increasing mouth secretions and by wednesday the daughter believes the started the pt on an antibiotic for pna, although this is not listed on the transfer paperwork. yesterday evening, the patient was noted to have a fever and hypoxia and was transported to ed for eval. . in the ed, initial vitals t 102, hr 111, bp 120/63, rr 20s, o2 sat 100% nrb -> 90% ra -> 99% 6l nc. labs notable for wbc 8.1 with 77.3%n, lactate 1.7, na 150, bun 36, cr 0.9, ua negative. cxr with small to moderate right pleural effusion with underlying infection that could not be excluded. given 4l ivfs with improvement in hr to 80s; however, bp trended down as low as 86/38. rij tlc placed and started on levophed gtt at 0.04 mcg/kg/min with bps to 116/66. also given vancomycin 1 gm iv x 1, zosyn 4.5 gm iv x 1, tylenol 1 gm pr, albuterol nebs and admitted to for further care. per ed discussion with family, pt is dnr but ok to intubate for now if necessary. . ros could not be performed with patient as not responding to questions or commands in mandarin. past medical history: h/o cva with l sided paralysis but contractures in all 4 extremities, peg dementia htn chf, unclear if systolic or diastolic spinal stenosis sciatica h/o peptic ulcer hypothyroidism osteoporosis rheumatoid arthritis h/o pna, utis mrsa carrier social history: widowed. mandarin speaking. per family, has resided in nh since cva 3-4 years ago. speaks occasionally in very short sentences to daughter but per and notes, pt mostly aphasic and non-verbal. no h/o tobacco but significant second hand smoke exposure. no illicits, etoh. family history: non-contributory physical exam: admission physical exam: t 98.2 bp 94/40 hr 87 rr 22-27 o2 sat 97% 4l nc gen - elderly female in no apparent distress, not responsive to commands in mandarin. briefly opens eyes to sternal rub. lying on left side heent - sclerae anicteric, difficult to assess mm as pt not cooperative with opening mouth. cannot assess jvp due to rij tlc. cv - rrr, no m/r/g appreciated lungs - decreased bs at right base without clear crackles appreciated, exam is limited by pt not taking deep breaths abd - soft, mod distended, + bs, peg in place with surrounding denuded area with macerated tissue. peg dressing c/d/i. ext - no le edema but edema noted in ues with l > r. wwp with 1+ pulses distally. neuro - lethargic, briefly opens eyes to sternal rub. no spontaneous movement of any 4 extremities. all 4 extremities with contractures. increased tone of rue. lue flaccid. + dtrs b/l. upgoing toe on left, equivocal on right. unable to assess remaining neurologic exam due to ms. skin - no rashes appreciated pertinent results: labs on admission: 12:20am blood wbc-8.1 rbc-3.19* hgb-9.6* hct-30.5* mcv-96 mch-30.1 mchc-31.5 rdw-15.0 plt ct-287 12:20am blood neuts-77.3* lymphs-17.6* monos-2.5 eos-1.8 baso-0.6 10:30pm blood pt-11.9 ptt-21.0* inr(pt)-1.0 10:30pm blood glucose-103 urean-36* creat-0.9 na-150* k-3.9 cl-114* hco3-29 angap-11 03:46am blood albumin-2.5* calcium-6.3* phos-3.0 mg-2.1 iron-49 . . . complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 04:51am 12.8* 2.89* 8.7* 26.7* 92 30.0 32.4 16.5* 994* source: line-picc 04:32am 13.1* 2.80* 8.3* 26.4* 94 29.7 31.5 16.5* 1002* source: line-picc 03:16am 12.6* 2.83* 8.4* 26.9* 95 29.5 31.1 16.3* 1019*1 source: line-picc 02:08am 8.9 2.84* 8.4* 26.8* 94 29.7 31.5 16.1* 967* source: line-picc 04:03am 10.2 2.81* 8.4* 26.8* 96 30.0 31.3 16.4* 993* source: line-picc 04:24am 8.0 2.67* 7.9* 25.6* 96 29.5 30.8* 16.4* 919* source: line-picc 04:15am 11.4* 2.84* 8.4* 26.9* 95 29.4 31.1 16.8* 971* . . renal & glucose glucose urean creat na k cl hco3 angap 04:51am 95 14 0.7 138 3.1* 96 33* 12 source: line-picc 12:42pm 3.9 source: line-pic 04:32am 105 13 0.6 139 3.8 99 32 12 source: line-picc 03:16am 102 12 0.7 134 3.7 98 source: line-picc 02:08am 118* 10 0.7 137 3.6 101 28 12 source: line-picc 08:02am 3.8 source: line-left picc 04:50am greater th1 source: line-picc 04:03am 112* 9 1.1 132* 7.6*2 101 25 14 source: line-picc 04:30pm 9 1.1 138 3.7 100 30 12 source: line-picc 04:24am 116* 8 1.1 141 3.8 100 29 16 source: line-picc 04:50pm 115* 8 1.3* 138 3.6 99 32 11 source: line-picc 04:15am 100 9 1.2* 138 3.7 97 32 13 . . enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 04:15am 4 22 100 0.2 source: line-picc 03:54am 8 22 98 0.2 . . chemistry totprot albumin globuln calcium phos mg uricacd iron 04:51am 8.2* 2.4* 2.0 source: line-picc 04:32am 8.1* 2.3* 2.0 source: line-picc 03:16am 8.0* 2.2* 2.0 source: line-picc 02:08am 8.1* 2.5* 2.2 source: line-picc 04:03am 7.8* 3.4 2.3 . . blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph caltco2 base xs aado2 req o2 intubat vent comment 01:09pm 32*1 53* 7.45 38* 10 not intuba2 01:09pm mix 32*1 51* 7.43 35* 7 11:18am 37.23 /19 40 pnd pnd pnd pnd pnd trach mask 01:47am 54*1 44 7.45 32* 5 10:17pm green-top/4 11:01am 37*1 53* 7.41 35* 6 02:15pm art 37.75 /24 7.51* 36* 9 intubated 02:06pm 37.76 /24 7.59*7 35* 11 intubated spontaneou8 green top 05:52pm art 88 44 7.47* 33* 7 09:19pm central ve9 39*1 56* 7.31* 30 0 04:58pm art 98 38 7.39 24 -1 12:42pm central ve9 08:07pm art 37.710 14/0 * 39 7.35 22 -3 431 73 intubated controlled 05:58pm art 127* 55* 7.22*11 24 -5 04:12am mix 02:54am art 36.8 /23 89 46* 7.38 28 0 not intuba2 . . whole blood, miscellaneous chemistry lactate 04:58pm 2.5* 12:42pm 1.8 04:25am 3.0* 08:07pm 1.8 05:58pm 5.1*1 02:54am 1.2 10:52pm 1.7 . . pleural pleural analysis wbc rbc polys lymphs monos 10:59am 72* * 88*1 4* 8* 25 cell differential pleural chemistry totprot glucose ld(ldh) 10:59am 0.0 75 40 ascites ascites analysis wbc rbc polys lymphs monos macroph other 03:09pm 218* 39* 11* 26* 0 62*1 1*2 pigment laden cells present atypical cells,refer to cytology reviewed by ,md on ascites chemistry totpro glucose creat ld(ldh) amylase totbili albumin 03:09pm 3.0 94 1.0 160 13 0.2 1.3 . . date 6 specimen tests ordered by all all blood culture blood culture not processed influenza a/b by dfa mrsa screen peritoneal fluid pleural fluid sputum stool urine all emergency inpatient urine urine culture-final {yeast} inpatient stool clostridium difficile toxin a & b test-final inpatient sputum gram stain-final; respiratory culture-final {staph aureus coag +, gram negative rod(s), gram negative rod #2, yeast} inpatient urine urine culture-final {yeast} inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient peritoneal fluid gram stain-final; fluid culture-final; anaerobic culture-final; fungal culture-preliminary; acid fast smear-final; acid fast culture-preliminary inpatient urine urine culture-final {escherichia coli} inpatient blood culture blood culture, routine-final inpatient mrsa screen mrsa screen-final {positive for methicillin resistant staph aureus} inpatient urine urine culture-final {yeast} inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture not processed inpatient pleural fluid gram stain-final; fluid culture-final; anaerobic culture-final inpatient influenza a/b by dfa direct influenza a antigen test-final; direct influenza b antigen test-final inpatient urine legionella urinary antigen -final inpatient mrsa screen mrsa screen-final {positive for methicillin resistant staph aureus} inpatient urine urine culture-final emergency blood culture blood culture, routine-final emergency blood culture blood culture, routine-final emergency other: 03:46am blood caltibc-189* vitb12-852 folate-greater th ferritn-177* trf-145* 03:46am blood tsh-2.2 03:46am blood free t4-1.1 . urine: 10:25pm urine color-yellow appear-clear sp -1.022 10:25pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg . micro: bl cx - no growth to date urine legionella - negative influenza dfa - negative sputum culture (): staph aureus coag +. moderate growth. 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. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. gram negative rod(s). moderate growth. gram negative rod #2. rare growth. yeast. sparse growth. urine culture (): yeast. 10,000-100,000 organisms/ml c. diff toxin: negative . cardiology: tte (): conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is an anterior space which most likely represents a fat pad. impression: normal biventricular cavity sizes with preserved global biventricular systolic function. mild aortic regurgitation. no significant pericardial effusion. increased pcwp. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . radiology: cxr: the heart is moderately enlarged and the aortic contour is tortuous. vascular calcifications are seen along the aorta and in the right neck. additionally, rounded calcification along the right mediastinal contour is atypical for lymph node calcification and may also represent vascular calcification. there is small to moderate right pleural effusion with adjacent atelectasis, although right lower lung infection cannot be excluded. there may also be tiny left pleural effusion with some atelectasis. the upper lungs are grossly clear, without evidence of pulmonary edema. degenerative changes are noted along the thoracic spine. impression: 1. marked cardiomegaly, without evidence of pulmonary edema. 2. right pleural effusion with atelectasis, although right basilar infection cannot be excluded. . port cxr post line - rij terminating in appropriate position, no ptx . final report reason for exam: pulmonary edema. acquired pneumonia. comparison is made with prior study performed . tracheostomy tube is in standard position. large right and small to moderate left pleural effusion are unchanged. cardiomediastinal contours are partially visualized and unchanged. mild interstitial edema seen in the left lung is stable. there is no pneumothorax. opacity in the left base is unchanged likely atelectasis. dr. approved: wed 12:02 pm . . ct abdomen history: -year-old woman with history of cva, dementia, hospital-acquired pneumonia, status post tracheostomy, now with emesis for four days. a gj tube. distended abdomen on exam. the patient underwent exchange of the gj catheter earlier today. comparison: none. technique: mdct axial images were obtained from the lung bases to the pubic symphysis following administration of 50 ml of optiray intravenous contrast that was hand injected via the left upper extremity picc line. multiplanar coronal and sagittal reformatted images were generated. ct abdomen with intravenous contrast: there is a moderate right and small left pleural effusion, with underlying atelectasis. there is fluid within the distal esophagus. the gastrostomy balloon is located within the stomach, and the jejunostomy catheter terminates in the jejunum. the liver is normal. the gallbladder is decompressed. the spleen is not enlarged. the pancreas, adrenals and kidneys are unremarkable. there are dilated proximal small bowel loops and decompressed diatal lops are seen, however contrast progresses into the decompressed loops consistent with a partial obstruction. there is a moderate amount of ascites within the abdomen and pelvis. the greater omentum is abnormal, with nonspecific soft tissue infiltration. this may be related to recent procedure/tube placement and reactive, but in the absence of recent instrumentation could be seen with neoplasm. the abdominal aorta is normal in caliber, with dense vascular atherosclerotic calcifications. ct pelvis with intravenous contrast: the uterus is not identified. two low- density ovoid soft tissue foci measuring up to 2.3 cm in diameter (2:66) in the left hemipelvis, one represents the ovary which contains a cystic mass. there is a foley catheter in the urinary bladder, which is decompressed. the rectum and sigmoid colon are unremarkable. there is diffuse soft tissue stranding consistent with anasarca. bone windows: there are severe compression deformities of l2, t11 and t9, with resultant narrowing of the spinal canal, most severely at t9 and t11. heterotopic ossification arises from the anterior aspect of the intertrochanteric region of the left femur is likely post-traumatic in etiology. impression: 1. partial small bowel obstruction with transition point in the right lower quadrant. 2. left ovarian cystic mass with thickening of the omentum and ascites is concerning for ovarian carcinoma, the ovarian mass could be further evaluated with ultrasound. alternatively, diagnostic paracentesis could be performed 3. moderate right and small left pleural effusions. 4. fluid in the distal esophagus. 5. g-tube balloon in the stomach, and jejunostomy catheter terminating in the jejunum. 6. compression deformities of t9, t11 and l2 with resultant narrowing of the spinal canal, significantly at t9 and t11. revised report was discussed with dr. at 9:30am on the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 9:32 am . . brief hospital course: female with h/o cva, dementia, ra who presented with fever and hypoxia to the icu . she was started on vanc, zosyn and levofloxacin for health care associated pneumonia vs. aspiration pna. hemodynamically she was stable and transferred to the general medicine floor . on the general medicine floor patient was continued for treatment of hap, had g tube replaced to a gj tube and thoracentesis to eval effusion. patient received lasix for diuresis. on the floor patient's blood pressure ranged from 92-141/56-87, was re-started on outpatient b-blocker and started on lasix diuresis. she was afebrile, pulse 97-118, 94-99 on 2 l. at 1830 patient was found to be tachypneic (rr 40s) and abg demonstrated co2 55, ph 7.22 and lactate of 5.1. patient was consequently intubated, required phyenlepineprine for pressor support and transferred to the . hospital course according to problem list as below. the patient was ultimately discharged with comfort measures. respiratory distress: patient known hap pna, large effusion and diastolic chf. acute episode requiring intubation most likely related to aspiration. patient with poor urine output, did not respond to lasix and dopamine drip support. continued zosyn and vancomycin for total 8 days treatment () of hap. scopolamine patch to decrease oral secreations. continued albuterol, ipratropium nebs prn for wheezing. from , patient was stable on ventilator, however experienced some apneic events due to oversedation and was responsive to narcan. on , after much discussion with hcp and family, mrs. , recieved a tracheostomy by thoracic surgery. on crepitus was noted around the trach site, thoracic surgery consulted, resolved without intervention. mrs. was gradually weaned off the vent from to using mmv overnight due to apnea and ps during most of the day. on , she had a possible aspiration event after gj tube replacement, however, she was monitored for infection/fever, which did not develop. a sputum culture from the trach revealed mrsa, however, the trach is likely colonized. before discharge, mrs. was tolerating her tracheostomy mask well with no signs of respiratory distress or infection. however, upon discharge after repeated lengthy discussions with her family, it was determined that ms. was to be treated with comfort measures, so her trach was capped, and started on morphine, ativan, and continued on albuterol nebs while breathing on room air. she was discharged comfortable and breathing room air in the high 80 percents. abdominal distension: patient noted to have abdominal distension on admission to . kub on with no obstruction, bowel regimen increased. pt noted to have increasingly decreased bowel sounds over next week, however portable supine on showed no obstruction. gj tube replaced by ir on , with subsequent emesis and drainage of gastric contents out of tract. ct scan abdomen showed properly placed gj tube, ascites and ovarian mass. diagnostic paracentesis cytology consistent with adenocarcinoma. g tube placed to suction and j tube to gravity. she was started on tube feeds until she started to drain dark brown mildly heme-positive material from her gastric tube. it was unclear if the drainage was either coffee ground emesis or feculent material from obstruction. she remained npo at discharge due to comfort measures. her g-tube was to gravity and j tube clamped. allergic reaction: on , day 7 of zosyn treatment, mrs. developed a rash on her torso that was maculopapular and erythematous. the rash ultimately spread to her upper and lower extremities, sparing her feet, palms and face. froom , the rash progressed to blister/bullae-like lesions, then began weepy before crusting and desquamating. zosyn and vancomycin were stopped due to concern of allergy and it is thought that the reaction most likely from zosyn and not vancomycin. the rash was treated with supportive care and sulfadine creme to prevent super-infection. due to insensible losses, fluids were repleated as needed. at time of discharge, rash resolved with minimal desquamation. hypotension: most likely combination of septic shock (related to hap) and cardiac failure (see below). lactate elevated on admission, trended downward. patient was slowly weaned off pressor support. no aggressive fluid resucitation due to overload on exam and cxr. over course of icu stay, mrs. had intermittent hypotension, usually related to over-sedation. when sedation weaned, blood pressure returned to her normal. mrs. ultimately tolerated lasix gtt started on later transition to q8 boluses, to diurese excess fluid off with a goal of negative 1 liter/day. upon discharge she was not on any diuretics with the aim of comfort measures. cardiac failure: ef demonstrated new regional wall abnormality and worsened mr, troponin and ck negative. ekg no st elevation. most likely suffered strain related to acute respiratory event. held outpatient bb and ccb due to low blood pressure and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. anemia: decreased to 24 from 29. drop most likely related to ivf and possible suppression for sepsis. iron studies consistent with anemia of chronic disease. patient required no transfusions. uti: urine with yeast on , foley was changed. on , pt became hypotensive and tachycardic, remained afebrile. urine grew e. coli, completed course of bactrim. rheumatoid arthritis: held azathioprine in setting of acute infection and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. osteoporosis: continued outpatient calcium and vitamin d and due to comfort measures at discharge it is not recommended that any of her outpatient medications be restarted. goals of care: ongoing discussion with family goals of care and patient's quality of life. after trying many interventions for her multiple medical problems, the patient seemed unlikely to recover. her daughter decided to switch from dnr to dnr/dni with no escalating care including pressors. after more repeated conversations, it was determined that ms. goal of care would be to maximize comfort measures. the icu team then withdrew invasive measures such as ventilation through tracheostomy, and plans for any future g tube use. she was started on morphine, ativan, and continued on albuterol nebs for comfort. the remainder of her home medicines and medicines in the hospital were discontinued. medications on admission: fleet enema daily prn natural tears 1 ddrop q4h prn lacrilube ointemnt qhs levothyroxine 125 mcg daily calcium carbonate 500 mg vitamin d 400 units daily prevacid 15 mg tab daily aricept 10 mg daily multi-delyn liquid 5 ml daily kcl 10 meq qmon,wed,fri metoprolol tartrate 25 mg daily vitamin c 500 mg (5ml) reglan 5 mg/5ml 10 ml tid scopolamine patch 1.5 mg/72hr behind ear q72h amlodipine 5 mg daily lasix 20 mg tab qod azathioprine 25 mg daily duoneb qid and q2h prn tylenol 650 mg prn docusate 100 mg prn milk of magnesia 30 ml prn dulcolax 10 mg pr prn tube feeds: jevity 1.2 at 60 ml/hr for 15 hrs off at 8am and on at 5pm. 30 ml h2o flush before and after medss via g tube. 300 ml h20 flushes q4h discharge medications: 1. morphine concentrate 5 mg/0.25 ml solution sig: 5-10 mg po q2h:prn as needed for pain or dyspnea. disp:*15 ml* refills:*0* discharge disposition: home with service facility: hospice discharge diagnosis: primary: pneumonia small bowel obstruction secondary to ovarian cancer acute renal failure secondary to hypovolemia now resolved . secondary: -asthma -dementia /alzheimers type -gait disorder -dysphagia discharge condition: comfortable, afebrile, stable vitals, extubated, npo, nonambulatory discharge instructions: you were admitted to the icu for respiratory distress, probable pneumonia, and small bowel obstruction secondary to ovarian cancer. you were treated with antibiotics and you were intubated due to difficulty breathing. you eventually had to have a tube placed in your trachea since you were intubated for such a long time. after several repeated discussions with your family it was decided that you would be provided with measures to maximize your level of comfot, but that we would discontinue attempts for invasive care and escalation of care. we also discontinued use of your feeding tube due to the small bowel obstruction. . you should not take any of your usual home medicines since you are now being medicated only for your own comfort. the only medicine that we will prescribe you is liquid morphine that you should take as needed for pain or until you have achieved comfort. . please take all medications as prescribed. please do not hesitate to return to the hospital if you have any concerning symptoms. followup instructions: none 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 enteral infusion of concentrated nutritional substances thoracentesis percutaneous abdominal drainage temporary tracheostomy percutaneous [endoscopic] gastrojejunostomy bronchoscopy through artificial stoma replacement of tube or enterostomy device of small intestine diagnoses: acidosis anemia, unspecified unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia severe sepsis unspecified acquired hypothyroidism candidiasis of other urogenital sites asthma, unspecified type, unspecified acute respiratory failure pneumonitis due to inhalation of food or vomitus osteoporosis, unspecified septic shock late effects of cerebrovascular disease, hemiplegia affecting unspecified side dermatitis due to drugs and medicines taken internally rheumatoid arthritis carrier or suspected carrier of methicillin resistant staphylococcus aureus alzheimer's disease dementia in conditions classified elsewhere without behavioral disturbance hyperosmolality and/or hypernatremia spinal stenosis, unspecified region unspecified intestinal obstruction chronic diastolic heart failure attention to gastrostomy malignant neoplasm of ovary other colostomy and enterostomy complication penicillins causing adverse effects in therapeutic use malignant ascites 

Answer: The patient is high likely exposed to