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: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia major surgical or invasive procedure: placement of central line (r ij under ultrasound) placement of arterial lines history of present illness: hpi: 56 f with no sig pmh presented to hospital in after 6 day illness described as fever, cough, dyspnea, and poor appetite. in ed, fever to 104 hr 130s bp 121/33, rr 40 o2 88% ra. cxr at osh suggestive of multilobar pna. pt was given ceftriaxone and azithro in ed and admitted to floor. overnight, pt continued to be tachypnic rr 40s, difficult oxygenating. pt was tried on bipap overnight. despite this at 4 am, hr increased 150s, rr 60s. abg: 7.27/? pco2 /84 on 100% bipap. a decision was made to intubate patient. post intubation abg 7.26/43/78 on fio2 100% simv 600/14/1.0/5 in addition, overnight her wbc fell from 10--> 7 and patient developed bandemia to 41%. antibiotics broadened from ceftriaxone/ azithro to zosyn, levo, flagyl. no lactate in outside hospital records. blood pressure remained stable, but due to difficulty with ventilation, a decision was made to transfer patient to hospital icu for swan. however, patient noted to be hypoxic on leaving hospital. her transfer paralyzed with vecuronium and re-routed to for further care. . on arrival, pt appeared ashen, diaphoretic. vs on arrival to were: t 102.7 hr 140s bp 150/60s rr 26 o2 94% on fio2 100% on ac 450/26/15/60 . immediately on arrival to , a rij line was placed under ultrasound guidance with 1 stick and a left a-line was placed after many attempts. past medical history: smoking (? copd) abnormal -> bilateral calcifications s/p tubal ligation "hoarse voice" social history: etoh: 3 drinks/day; more on weekend tob: 1ppd x years works with stained glass. married. has two daughters. daughter is a pa at . family history: nc physical exam: vs: t 102.7 hr 140s bp 112/ 63 rr 26 o2 89% on ac 450/26/1.0/15 gen: middle aged f heavily sedated, initially not moving at all paralysis, but increasing spontaneous movements to stimulation heent: pupils sl assymmetric r(2) > l(1), both minimally reactive. raises eyebrows to stimulus. neck: thick. no inc jvp visible lungs: coarse breath sounds throughout anteriorly. no wheezes. cv: tachycardic, regular. no m/r/g. abd: hypoactive bs. soft. sl distended. extr: edema. 2+ dp, radial pulse thready intermittently. neuro: heavily sedated. initially flacid. pertinent results: on admission : cxr: bilateral dense infiltrates l > r. r diaphragm still sharp. ? b/l pneumonia vs pulm edema vs ards. . head ct: osh negative for bleed; midline shift . chest ct: () 1. no evidence of pulmonary embolism. 2. moderate bilateral pleural effusions, with compressive atelectasis. 3. multifocal areas of lung consolidation. . ekg: sinus tach 140s. no acute st segment changes . ruq u/s: impression: fatty infiltration of the liver. please note that more advanced liver disease and other types of liver disease, including cirrhosis/fibrosis, cannot be excluded by ultrasound in the presence of fatty infiltration. no evidence for cholecystitis. . osh labs: : 10.1/42.8/215 (89n, 8 b)and na 121 : 7.0/40.1/183 (49n, 41b) : 8.0/39.9/192; na 128, k 4.1, cl 95, c 22, bun 25, cre 1.3, gluc 136, ca 8/ mg 2.0/phos 4.0 amylase/lipase normal ast 157/ alt 91/ alk phos 120/ t bili 1.0/ alb: 2.8 . initial abg: 7.23/55/70; lactate 1.3 04:06am blood wbc-10.3 rbc-3.83* hgb-12.3 hct-36.1 mcv-94 mch-32.1* mchc-34.0 rdw-14.1 plt ct-446* 04:06am blood glucose-83 urean-21* creat-1.1 na-138 k-3.4 cl-100 hco3-20* angap-21* 04:57am blood glucose-81 urean-24* creat-1.1 na-140 k-3.6 cl-102 hco3-23 angap-19 04:57am blood alt-36 ast-38 ld(ldh)-298* alkphos-152* totbili-0.6 07:45pm blood alt-91* ast-157* ck(cpk)-587* alkphos-120* amylase-35 totbili-1.0 07:45pm blood lipase-12 04:06am blood calcium-9.4 phos-4.6* mg-1.7 09:40am blood tsh-0.95 08:56am blood type-art temp-38.6 rates-/15 peep-5 fio2-40 po2-97 pco2-41 ph-7.45 calhco3-29 base xs-3 intubat-intubated vent-spontaneou 03:11am blood lactate-1.1 06:21pm urine blood-lge nitrite-neg protein-30 glucose-neg ketone-50 bilirub-neg urobiln-neg ph-6.5 leuks-mod 06:21pm urine rbc->1000* wbc-48* bacteri-many yeast-none epi-<1 brief hospital course: a/p: 56 yo female transferred to from hospital with severe bilateral pneumonia, now known to be legionella based on urinary ag from osh and respiratory culture findings. . 1. respiratory failure: pt was in ards on admission and hypoxemic. had been intubated at the osh but was difficult to ventilate and required paralytics to get her to breathe in sync with the ventilator. she was paralyzed with cisatrucurium for one day, then paralysis was lightened as the patient was able to work with the vent. she was kept on ceftriaxone and azithromycin for presumed community-acquired pneumonia until the urinary legionella ag from the osh came back positive. ceftriaxone was then discontinued, and the patient completed a 14 day course of azithromycin for legionella pneumonia. for sedation, she was on versed and fentanyl which both needed to be escalated to keep her sedated. after a week, she was switched over to propofol for better sedation and to prevent further escalation of fentanyl/versed. she was volume overloaded throughout the course of her ards due to acute renal failure requiring 3 days of hemodialysis. once the arf resolved, she began to mobilize fluids on her own and diurese. with diuresis, her oxygenation began to improve and she was able to tolerate extended trials of pressure support. she was given boluses of lasix, then a lasix gtt, to enhance her diuresis with the goal being extubation. she was extubated on and did well for the first twelve hours. however, at approximately 2am, her o2 sats began to drop on 4l nc and she became tachypneic with a rr in the 50s. she was placed on facemask, then a nrb to keep her sats in the 90s. a cxr was taken at the time and looked like she was in chf. her abg at the time was 7.41/45/152 so she was kept on 100% fm and given 40mg lasix iv. attempts were made at noninvasive interventions with further diuresis and a trial of bipap but the patient began to tire and she was reintubated to improve her respiratory status. ekg and cardiac enzymes were negative, excluding a cardiac cause for her decompensation. a ct scan was negative for pe, but did show moderate sized bilateral pleural effusions with compressive atelectasis. she also had thicker sputum, a fever, and an elevated white count, concerning for perhaps a vap. empiric antibiotic therapy was started (piptazo, levaquin, and vanco). once reintubated, her sedation was kept light and the patient was able to maintain her oxygenation on settings of ac 500x12, .4, and 10 of peep. she was very sensitive to the peep, leading us to believe that the etiology for her desaturation after extubation was decruitment of some critical number of her alveloi, causing atelectasis and an inability to maintain her oxygentation. she was given boluses of lasix to aid her diuresis, with the goal of being net negative 2l each day. the pt continued to have fevers and a urine culture showed probable enterococcus. ciprofloxacin 500mg was started. sedation was decreased and the patient was extubated on the . the patient tolerated the extubation well and did not have any further supplemental oxygen requirements. the patient remained afebrile and the course of ciprofloxacin was terminated after 5 days. would recommend that patient get a cxr as an outpatient following discharge to ensure that pneumonia has fully cleared. clinical exam on discharge suggests that pneumonia has resolved. . 2. acid base disorders: initially the patient was acidemic with a primary respiratory acidosis. she then developed an anion gap metabolic acidosis (felt to be due to lactate) and a nongap metabolic acidosis (due to fluid resuscitation and renal failure). she was put on a bicarb gtt to correct her acidosis with good effect on her ph, but due to volume overload, it could not be continued. her ph normalized with hemodialysis and then became alkalemic after her first extubation, likely due to a contraction alkalosis during diuresis. the alkalosis resolved after extubation. however, prior to discharge her labs were suggestive of a metabolic acidosis and alkalosis. this was thought to be related to the initiation of hydrochlorothiazide for blood pressure control. hctz was therefore stopped and it is recommended that patient's primary care physician address the best intervention for blood pressure control. . 3. tachycardia: she was tachycardic on presentation, but it resolved with treatment of her hypoxia. she was intermittently tachycardic throughout the hospital course, but usually only in the settings of agitation, fever or respiratory distress. . 4. bp management: she was hypotensive on admission and required levophed until . she remained normotensive for the remainder of her hospital course, except for periods of acute agitation or respiratory distress when she would become acutely hypertensive. on admission, many attempts were made to place an a-line in either of her wrists, and eventually anesthesia was able to get a line access in her l radial artery. she had multiple ecchymoses from these attempts on both of her forearms. once her original a line was lost, she had an a line placed in her r dorsalis pedis artery and then her r radial artery. bp normalized without any further fluid therapy and the pt tolerated the diureses of 2-3l daily well. once extubated the patient developed hypertension and was started on hctz 12.5mg po daily. as mentioned above, this was stopped secondary to acid-base abnormalities and we recommend that hypertension be addressed on an outpatient basis. . 5. sodium balance: she was hyponatremic on admission with a na of 128, thought to be due to the legionella infection. it slowly resolved with fluid resuscitation, until she became hypernatremic and hyperchloremic. free water boluses were added to her tf to correct her hypernatremia, but were discontinued in light of her volume status. they were restarted after she became reintubated at 250ml q4 until her na came down to 145. sodium levels remained within normal levels with diureses and no free water boluses were required. . 6. leukocytosis: she had a leukocytosis on presentation, likely due to her pneumonia. it was also compounded by steroids as she failed her -stim test and was treated with 7 days of hydrocortisone and florinef for adrenal insufficiency, (last day was ). the only microbiology culture which ever grew a positive result was her respiratory culture from which grew gram negative rods, thought to be legionella. the final result is still pending as it was sent to the state lab. all other cultures results (stool, sputum, urine, and blood) were negative. antibiotics were started on her reintubation for empiric therapy of a vent-associated pneumonia. however, she developed a drug rash and a fever while on those abx (first piptazo, then cefepime), so all abx were discontinued as the probability of her having a vap causing her reintubation was very low. the patient continued to have fevers and a urine culture was positive for enterococcus. ciprofloxacin was given for five days. the fever resolved and the patient remained afebrile. . 7. arf: her cr was 1.3 on admission and peaked at 5.1. her renal failure was thought to be due to atn hypotension while septic. while in arf, she was virtually anuric and became volume overloaded with increasking k, increasing ph, low ph, and difficulty making progress with the ventilator. she was initially unresponsive to lasix and thus a quenten catheter was placed in her r femoral artery for hemodialysis. she was on hd for three days and tolerated it very well without any episodes of hypotension. after hd, she began to make her own urine and appeared to be in post-atn diuresis. lasix was given, iv and as a gtt, to assist in diuresis with good effect. after her reintubation, she required a ct scan with contrast to r/o a pe and we attempted to protect her kidneys with bicarb ivf and mucomyst. her cr did not bump post-scan, and her urine output continued to be 1-2l per day. the cr came down to 0.9 and the patient was diuresing well. however, prior to discharge her cr was ranging from 1.1-1.2. her baseline is likely much lower and there is likely some element of renal dysfunction secondary to her prolonged illness and hospital course. it is recommended that her lab values be followed up as an outpatient. . 8. hyperglycemia: the patient was placed on an insulin gtt during the acute phase of her illness to maintain tight glycemic control while she was critically ill. she had no h/o dm, and as her illness resolved, she was able to be weaned to a riss with good results. fs were typically within 100s-140s. . 9. anemia: the patient had a macrocytic anemia on presentation. hemolysis labs were negative, b12 and folate were high. likely etiology is etoh-induced. our goal for mrs. was to keep her hct above 24. she required two transfusions, one unit of prbc on and one unit on . she tolerated both transfusions well without any signs or symptoms of fever, chills, or adverse reactions. she did not require any further transfusions. anemia had improved on discharge. . 10. transaminitis: on admission, she had ast>alt and alk phos 120, felt to be due to etoh use. the ratio of her lfts then changed, with alt>ast and alk phos becoming even higher. the etiology of her transaminitis is unclear. is 0.4 and patient does not appear jaundiced, so likely not obstructive. on exam, she had no hepatosplenomegaly or abdominal pain. most likely cause was medication, as lfts continued to trend downward with the resolution of her illness and removal of many of her medications. a ruq ultrasound during her admission reveladed a fatty liver but no evidence of biliary pathology. lfts should be followed up on an outpatient basis to ensure that they continue to trend downward. . 11. neuro status: on presentation, mrs. was unresponsive but on high doses of sedation, analgesia, and paralytics. when the medication was weaned down, her mental status did not improve, her pupils were asymmetric and sluggish, and she appeared to have upgoing toes bilaterally and hyperreflexia on the right. a ct of her head was done to assess for intracranial pathology and it was negative. her sedation was changed to propofol as she began to develop a tolerance to fentanyl and versed and required higher doses to achieve adequate sedation. once weaned to propofol, it seemed that her neuro status improved. she was able to follow commands and interact more appropriately. on extubation, she asked appropriate questions and was able to be oriented. she was awake, alert and appropriate. her family reports that she is not quite at her baseline mental status. we would recommend following this closely and evaluating further if she does not return to her baseline in the near future. . 12. fen: the patient had an ogt placed during her admission and received tube feeds at goal of 40cc/hr. had difficulty with diarrhea at start of illness, but stool cx for c diff were negative. the patient was switched to po intake after extubation and tolerated it well. given patient's significant etoh history the patient should be continued on thiamine and folate. . 13. code status: full code . 14. communication: with husband , daughter . medications on admission: aspirin for headache dristan cold medicine discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. lorazepam 1 mg tablet sig: 1-4 tablets po q4-6h (every 4 to 6 hours) as needed for anxiety. 4. ipratropium bromide 18 mcg/actuation aerosol sig: six (6) puff inhalation q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: medical center - discharge diagnosis: pneumonia discharge condition: stable discharge instructions: please discharge patient to medical center. followup instructions: please follow up with your pcp after leaving rehabilitation. your physician should check chest xray and labs to make sure everything has returned to . md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis arterial catheterization transfusion of packed cells diagnoses: urinary tract infection, site not specified acute kidney failure, unspecified other pulmonary insufficiency, not elsewhere classified iron deficiency anemia secondary to blood loss (chronic) hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified alkalosis pneumonia due to legionnaires' disease 

Answer: The patient is high likely exposed to