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: vancomycin / meropenem attending: chief complaint: altered mental status major surgical or invasive procedure: bronchoscopy and bronchoalveolar lavage history of present illness: 48 yo m with c4 tetraplegia s/p diving accident, trach placement (weaned off), recent dvt on coumadin and with ivc filter presenting from with altered mental status. about 10 days ago, he started to experience altered thinking, which was initially thought to be medications (recently had started remeron and buspar) vs poor sleep so medication doses were reduced. on , mental status seemed worse, pt thought he was holding things that werent there, or that he could walk. wbc elevated on , empirically started on cipro and linezolid for a lll infiltrate on cxr at . on , mental status had iproved and wbc decrased, however on am of admission mental status was worse. aox3, but at he thought he was walking around and is occasionally not oriented to self. . about 10 days ago he also had a suprapubic catheter placed. has not had any fevers, chills, night sweats. no diarrhea, has chronic constipation. is unable to move all 4 extremities. no recnet nausea/vomiting. has had increased secretions and has required more frequent suctioning at rehab, and frequent desats to 80s. also has increased cough with yellow sputum. . in ed vs were 69 125/81 27 93-94% on 2l nc. he was given fluconazole 150 mg po x1, ceftiraxone 1 gm iv x1. head ct neg for acute bleed, cxr showed small rll opacity. on ua, moderate yeast, few bacteria, wbc , tr leuks. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: parkinson white syndrome s/p ablation sci at c3-c4, has a capped trach and a g tube dvt on coumadin, s/p ivc filter social history: lives at , has tetraplegia. wife is very involved in his care family history: non-contributory physical exam: on admission: vs: 97.9 120/82 55 18 97% 3l ga: aox3, nad heent: perrla. mmm. no lad. no jvd. aspen collar in place, unable to move neck. cn ii-xii grossly intact. cards: rrr s1/s2 heard. no murmurs/gallops/rubs. pulm: auscultated anteriorly, no rales, rhonchi appreciated abd: soft, nt, +bs. no g/rt. neg hsm. neg sign. extremities: wwp, no edema. dps, pts 2+. has hose, support boots skin: no rashes neuro/psych: cns ii-xii intact. unable to mvoe extremities. knows months fo the year backwards, conversational, alert and oriented to place, date, self. pertinent results: 12:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:43am blood type-art fio2-70 po2-112* pco2-70* ph-7.26* caltco2-33* base xs-1 intubat-not intuba 05:35am blood type-art po2-336* pco2-51* ph-7.37 caltco2-31* base xs-3 10:34am blood type-art po2-54* pco2-36 ph-7.52* caltco2-30 base xs-5 01:16pm blood type-art temp-36.7 rates-/18 peep-10 fio2-50 po2-141* pco2-55* ph-7.32* caltco2-30 base xs-1 intubat-intubated vent-spontaneou 06:48am blood type-art po2-120* pco2-35 ph-7.46* caltco2-26 base xs-2 01:27pm blood type-art temp-37.2 rates-16/2 tidal v-500 peep-10 fio2-40 po2-134* pco2-38 ph-7.42 caltco2-25 base xs-0 intubat-intubated 03:44am blood type-art temp-37.3 fio2-40 po2-178* pco2-36 ph-7.48* caltco2-28 base xs-4 intubat-intubated 05:35am blood lactate-1.6 10:34am blood lactate-1.6 . discharge labs blood wbc-6.7 hgb-12.4* hct-37.6* plt ct-361 blood pt-25.7* ptt-32.0 inr(pt)-2.5* blood glucose-100 urean-11 creat-0.4* na-139 k-4.2 cl-104 hco3-29 angap-10 blood alt-205* ast-63* alkphos-116 totbili-0.2 blood calcium-9.0 phos-3.6 mg-2.0 . blood cx ngtd . 2:10 pm urine **final report ** urine culture (final ): yeast. >100,000 organisms/ml.. staph aureus coag +. 10,000-100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | gentamicin------------ <=0.5 s levofloxacin---------- =>8 r nitrofurantoin-------- 32 s oxacillin------------- =>4 r tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s . 3:30 pm sputum **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): commensal respiratory flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. yeast. sparse growth. gram negative rod(s). rare growth. staph aureus coag +. rare 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. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . gram negative rod #2. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s . 1:01 pm bronchial washings +pmns, all cx negative for growth . 1:01 pm rapid respiratory viral screen & culture- negative . 12:24 pm urine legionella negative . bc x2 no growth . 6:49 pm urine source: suprapubic. **final report ** urine culture (final ): yeast. 10,000-100,000 organisms/ml.. staph aureus coag +. 10,000-100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | gentamicin------------ <=0.5 s levofloxacin---------- =>8 r nitrofurantoin-------- 32 s oxacillin------------- =>4 r tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s . . radiology . xr chest (portable ap) study date of 12:35 pm findings: a single portable semi-upright view of the chest was obtained. an ill defined density in the right lower lung is present. there is no effusion or pneumothorax. the cardiomediastinal silhouette is unremarkable allowing for patient position and technique. osseous structures are intact. impression: ill defined density in right lower lung, which may represent a small focus of aspiration or early developing pneumonia. . ct head w/o contrast study date of 12:57 pm findings: there is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. ventricles and sulci are normal in size and symmetric in configuration. there is no shift from normally midline structures. -white matter differentiation is well preserved. mucosal thickening is seen within scattered ethmoid air cells and there is partial opacification of mastoid air cells bilaterally. the remainder of the visualized paranasal sinuses are clear. no osseous abnormality is identified. impression: no acute intracranial process. limited exam due to motion artifact. . ct c-spine w/o contrast study date of 6:36 pm findings: compared to , there is unchanged anterolisthesis of c3 on c4 measuring about 7.5 mm (grade 2). unchanged angulation of the anterior fixation rods with indentation on the right sided oro- and hypo-pharynx. unchanged inferior displacement of the intervertebral disc spacer. there is increased lordosis at c2/c3, stable. patient is status post laminectomy at c3/c4, unchanged kinking of the spinal cord at c3/c4. impression: no significant change compared to with 7.5 mm anterolisthesis of c3 on c4. . xr chest (portable ap) study date of 2:16 pm impression: lucency projected over the left hemidiaphragm is most likely within a loop of bowel rather than a pleural gas collection, this may either be subphrenic or within a diaphragmatic hernia, which could be ellucidated with ct, if clinically warranted. . ct head w/o contrast study date of 11:38 pm findings: there is no evidence of hemorrhage, infarction, shift of normally midline structures, discrete masses, or brain edema. the ventricles and sulci are normal in size and configuration. minimal mucosal thickening is noted within scattered ethmoid air cells. there is partial opacification of bilateral mastoid air cells. the remainder of the visualized paranasal sinuses is clear. again demonstrated is dramatic subluxation of c3 on c4, better seen on the cervical spine ct of . impression: cervical spine subluxation. otherwise normal study. . cta chest w&w/o c&recons, non-coronary study date of 11:29 am findings impression: 1. no evidence of pulmonary embolism as questioned. 2. left lower lobe volume loss, with low density plugging of the left lower lobe bronchus. 3. nodular opacities noted in the right lower lobe, along with ground glass opacity seen in the left upper lobe. findings most likely represent superimposed infectious process. . . cardiology . ecg study date of 11:06:26 am sinus bradycardia. compared to the previous tracing the rate is slower. tracing #2 . ecg study date of 10:01:56 am sinus rhythm. normal tracing. compared to the previous tracing of no major change. tracing #1 read by: , intervals axes ratepr qrs qt/qtc p qrs t 64 134 96 422/429 69 0 17 brief hospital course: 48 yo m with c4 tetraplegia s/p mva, s/p trach/peg placement, recent dvt on coumadin with ivc filter who was admitted with uti and pna and transfered to the icu for hypercarbic respiratory failure. pt improved with iv cefepime/linezolid for hap and was treated for yeast in urine cx with iv fluconazole. he had another episode of respiratory decompensation on likely due lll collapse on cxr. he improved with resp therapy, suctioning and increased o2. pt had a cta on with no pe but consolidation and collapse lll. after this episode, he continued to improve from a respiratory standpoint. . # pneumonia/respiratory failure: pt was admitted with confusion and developed acute respiratory distress requiring micu transfer. a bronch performed in the micu revealed severe lll and lul mucous plugging that was difficult to clear with serial washes and he ultimately required placement on a ventilator via trach for hypercarbic respiratory failure. infectious work up included a head ct that was negative and bal cultures that were positive for yeast and mrsa. pt was treated with linezolid, cefepime, and fluconazole for hap. pt was transferred to the on and had another episode of respiratory decompensation with bradycardia on that was felt likely due to mucus plugging. his status improved with suctioning, mie and nebs. pt underwent a cta on which did not show any evidence of pulmonary embolism but there was left lower lobe volume loss, with low density plugging of the left lower lobe bronchus and nodular opacities noted in the right lower lobe, along with ground glass opacity seen in the left upper lobe. given these persistent findings, pt was continued on iv antibiotics to complete a 14 day course of iv cefepime and linezolid. his respiratory status continued to improve with aggressive respiratory therapy support, suctionning and a new turing schedule with less time spent on his left side (1 hour on left side and 2 hours on right) to maximize ventilation on that side. . # uti/suprapubic cath: patient has a suprapubic catheter and both mrsa and yeast on ucx. urology was consulted and did not want to change out suprapubic catheter given that it was recently placed and the track is likely not epithelialized. he was treated with fluconazole, linezolid, and cefepime as above. fluconazole finished and linezolid to finish . on suprapubic catheter was noted to be leaking and urology consult felt that could be due to bladder spasm vs uti. by the time of discharge, the leak had improved significantly and pt will need to follow up with his urologist. . # previous dvt on warfarin: patient presented with an elevated inr at 4.1 in the setting of acute illness/infection. warfarin was held until inr fell to ~3 and then restarted at lower dose. his inr was very labile in house likely due to medication interactions and lmwh was started at 1mg/kg . this can be stopped when inr is >2 for over 24 hours and will need to be reviewed at with daily inrs until it has stabilized. . # s/p c4 spinal injury: neuro status at baseline. he requires an aspen collar in place at all times with q2h turns. he was continued on his home inhalers and prn nebs. he is on oxycodone prn for pain with a bowel regimen. turns were changed to maximize ventilation 1hr left 2 hours on right. pt was continued on high flow 50% via trache mask and this will need to be weaned at . . # lfts: patient was noted to have mildly elevated lfts and on the alt had risen to c200. this was felt likely antibiotics/fluconazole. fluconazole was stopped on as likely offending and completed course. lfts will need to be trended at rehab to ensure resolution . # poor po intake: noted reduced po intake. prn peg feed. improved on discharge. will need nutrition support and calorie counting at rehab. . inactive/chronic issues: . # confusion: likely secondary to infection/respiratory failure. ct-head was performed for anisocoria and was normal. confusion resolved with resolution of infection. anisocoria resolved . # anemia/thrombocytosis: at baseline. medications on admission: -linezolid 600mg q12hrs -tylenol 650 mg po q4hrs -combivent neds q4hrs -alendronate 70 mg daily -calcium polycarbophil 1250mg po bid prn -cholestyramine 4gram po bid prn -ciprofloxacin 500mg po q12 -clotrimazole/betamet 1-0.5% top cream -colace 100mg po bid prn -ipratropium 0.5mg neb q4hr prn -levalbuterol 1.25mg q4hrs prn -lidocaine patch -lorazepam 1mg q6hr prn -maalox/mylanta 30ml q4hr prn -magic bullet suppository 10mg pr daily -midodrine 10mg po -milk of magnesium 30ml po daily prn -nystatin 15gm powder topical -omeprazole 40mg daily -ondansetron 4mg po tid prn -oxycodone 10mg q3hr prn -percocet 1 tab q4hr prn -artificial tears both eyed qid prn -psyllium 1 packet po daily -senna 2 pills po bid -theophylline 100mg po bid -warfarin 3.5mg po daily discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q4h (every 4 hours) as needed for pain, fever. 2. clotrimazole 1 % cream : one (1) appl topical (2 times a day). 3. betamethasone dipropionate 0.05 % cream : one (1) appl topical (2 times a day). 4. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day) as needed for constipation. 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 6. lorazepam 0.5 mg tablet : one (1) tablet po bid (2 times a day) as needed for anxiety. 7. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension : thirty (30) ml po qid (4 times a day) as needed for abd discomfort. 8. simethicone 80 mg tablet, chewable : 0.5-1 tablet, chewable po qid (4 times a day) as needed for gas. 9. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 10. magnesium hydroxide 400 mg/5 ml suspension : thirty (30) ml po daily (daily) as needed for constipation. 11. miconazole nitrate 2 % powder : one (1) appl topical (2 times a day). 12. ondansetron 4 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 13. oxycodone 5 mg tablet : two (2) tablet po q3h (every 3 hours) as needed for pain. 14. polyvinyl alcohol 1.4 % drops : 1-2 drops ophthalmic prn (as needed) as needed for eye discomfort. 15. psyllium packet : one (1) packet po daily (daily) as needed for constipation. 16. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 17. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 18. cholestyramine-sucrose 4 gram packet : one (1) packet po bid (2 times a day). 19. midodrine 5 mg tablet : two (2) tablet po daily (daily). 20. acetylcysteine 20 % (200 mg/ml) solution : 2-3 mls miscellaneous q6h (every 6 hours) as needed for mie: as needed for mie. 21. sodium chloride 0.65 % aerosol, spray : sprays nasal tid (3 times a day) as needed for dry nose. 22. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 23. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) nebule inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 24. ipratropium bromide 0.02 % solution : one (1) nebule inhalation q4h (every 4 hours). 25. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) nebule inhalation q2h (every 2 hours) as needed for shortness of breath or wheezing. 26. linezolid 600 mg tablet : one (1) tablet po q12h (every 12 hours) for 1 days: to complete 14 days course - last day . 27. enoxaparin 80 mg/0.8 ml syringe : eighty (80) mg subcutaneous q12h (every 12 hours): to continue until inr >2 for two days. 28. sodium chloride 0.9 % 0.9 % parenteral solution : three (3) ml intravenous q8h (every 8 hours) as needed for line flush. 29. cefepime 2 gram recon soln : one (1) recon soln injection q12h (every 12 hours) for 5 days: to complete 14 days to finish . 30. morphine 5 mg/ml solution : 2-4 mg injection q2h (every 2 hours) as needed for dyspnea, pain. 31. alendronate 70 mg tablet : one (1) tablet po once a week. 32. lorazepam 0.5 mg tablet : one (1) tablet po hs (at bedtime) as needed for anxiety. 33. lorazepam 0.5 mg tablet : one (1) tablet po twice a day as needed for anxiety. tablet(s) 34. warfarin 1 mg tablet : 3.5 tablets po once daily at 4 pm. discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: pneumonia respiratory failure urinary tract infection abnormal liver function tests likely due to antimicrobials . secondary diagnoses: -parkinson-white syndrome c4 tetraplegia deep vein thrombosis on warfarin s/p inferior vena cava filter discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: it was a pleasure taking care of you during your stay at the . you came to the hospital with confusion and breathing difficulties and were found to have a urine infection and a lung infection. you had considerable breathing problems and required ventilation in the icu. you underwent broncoscopy to help clear mucous from the lungs and to identify the bacteria causing your pneumonia. you were treated with broad spectrum antibiotics for the two infections and you were weaned off the ventilator and coped well on the trache mask. you were transferred to the medical floor where you wre stable other than an episode of difficulty in breathing and requiring use of your mie and suctioning. this was likely due to a mucus plug and resolved after the above. other considerations at the time included the low probability of a blood clot on the lung which we investigated with a ct scan of your chest with contrast to look at the blood vessels. this showed no evidence of clot but did reveal infection and collapse at your left lung base. in order to improve your respiratory status we instituted a new turning regime, having less time on your left side. this along with regular use of our mie and respiratory therapy was used to good effect and you improved. you were at baseline at discharge back to and will complete 14 days of the linezolid and 14 days of the iv antibiotics. there was evidence of yeast in your phlegm and in your urine and you were treated for a total of 7 day with the anti-fungal fluconazole. you also noted considerable leakage from your suprapubic catheter and you were reviewed by urology who reassured that this as not uncommon and can be due to bladder spasm. this leakage improved during your stay. you should follow up with your urologist regarding your suprapubic catheter on discharge. your inr was initially high and your dose was reduced given your antibiotics which can raise the level. we increased the dose and coevered you with enoxaparin (another blood thinner) until you level is high enough. your inr on discharge was 2.5 and your warfarin dose was changed back to your normal. your liver function tests were also found to be abnormal on transfer to the and these slightly increasd duering your stay. this is likely due to your antibiotics and fluconazole but should be monitored at . you were discharged to . . changes to medications: we continued linezolid and you have one further day we stopped ciprofloxacin we started iv cefepime you should continue this for more days you were admitted on oral linezolid and should continue this for 1 more days we added regular lorazepam at night to help with your sleep we stopped theophylline and this should be reviewed at we stopped the lidocaine patch and this should be reviewed at . your inr was erratic and thus we changed the dose of warfarin - currently this at 4mg on and decreased to home dose 3.5mg on but should be reviewed at with daily inr checks. we started enoxaparin and this should be stopped once your inr is >2.0 for over 24 hours. you are on enoxaparin and this should be stopped when your inr is >2 for over 24 hours. followup instructions: you should make an appointment to see your urologist on discharge regarding your suprapubic catheter procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours enteral infusion of concentrated nutritional substances arterial catheterization closed [endoscopic] biopsy of bronchus diagnoses: pneumonia, organism unspecified anemia, unspecified hyposmolality and/or hyponatremia candidiasis of other urogenital sites atrial flutter pulmonary collapse acute respiratory failure long-term (current) use of anticoagulants personal history of venous thrombosis and embolism accidents occurring in residential institution delirium due to conditions classified elsewhere other abnormal blood chemistry gastrostomy status quadriplegia, unspecified tracheostomy status anomalous atrioventricular excitation foreign body in larynx late effect of spinal cord injury late effects of other accidents inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation 

Answer: The patient is high likely exposed to