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: penicillins attending: chief complaint: shortness of breath, altered mental status major surgical or invasive procedure: none history of present illness: 54 year old man with history of hep c, chronic extremity ulcers, restrictive lung disease, recurrent pe who presents with shortness of breath and confusion. the records of his inital presentation are not clearly documented. he was at home with his wife who found him with left sided back pain and minimal responsiveness. she called ems. when ems arrived to his home, he was hypoxic and met by his neighbors. . in the ed, his initial vitals were 98f, 118, 103/64, 25 86%ra->97%nrb. he received empiric lasix 80 iv x1, and levofloxacin 500 mg x1. he was started on a nitroglycerin drip but this was stopped when his pressure dropped to 70s systolic. an ekg was interpreted as sinus tach with no specific st-t changes. he voided 550 cc of brown urine without a foley. he received an empiric heparin bolus of 5000 units but the heparin was stopped when his inr came back at >10. he was transfered for further evaluation. ros: he states that he had a fever 2 days ago. he denies cough or chest pain. he denies abd pain but was having burning on urination. has pressure in his bladder. he has no rash. past medical history: 1)? buerger's disease vs. livedoid vasculopathy - per prior notes has had extensive work-ups by dermatology, rheumatolgy, plastics, etc. essentially excluded a diagnosis of cryoglobulinemia, while a presumptive diagnosis of buerger's or lv was made. the patient is on nifedipine to increase vasodilation and has been counseled to stop smoking many times. 2)chronic bilateral u+l extremity ulcers - complication of his vaculitis- ? pyoderma grangulosum 3)chronic pain multiple ulcers 4)sinus tachycardia, presumed reflex sympathetic dystrophy 5)remote history of testicular cancer in status post orchiectomy, with recurrence in treated with xrt and lnd. 6)bilateral pes , on coumadin 7)hypersensitivity pneumonitis versus boop versus nsip (restrictive pfts fev1 57%, dsb 61% in ) 8)hypothyroidism 9)hepatitis c (genotype 1) grade inflammation 2, stage 0 fibrosis 10)gerd - on ppi at home 11)s/p mva in with traumatic spleen rupture, bilateral open tibial fractures, and head trauma. 12) influenza pneumonia . social history: 1 ppd x 30 yrs. (+) history of ivdu, quit in . no ethanol use. lives with his wife in . currently unemployed family history: grandfather s/p mi in 70s. grandmother died in her sleep of unknown cause in her 70s. no family history of cancer. cousin with anti-phospholipid antibody. physical exam: upon arrival to the micu: vs: 99.2f (ax) 114 117/63 16 92%nrb gen: nad, talkative heent: at, nc, perrla (4->3 bilat), eomi, no conjuctival injection, anicteric, op clear, mmm, neck supple, no lad, no carotid bruits. no neck stiffness cv: tachy. regular. no m/r/g pulm: no crackles. diffuse rhonchi bilat. no dullness abd: healed surgical ex-lap scar. soft, nt, mild distension, active bowel sounds, no hsm ext: warm, dry, dopplerable pulses. sclerosed lower extremity skin. no femoral bruits neuro: alert & oriented to person, place, date. cn ii-xii grossly intact, 5/5 strength throughout. no sensory deficits to light touch appreciated. no asterixis psych: appropriate affect. awake requiring frequent re-direction pertinent results: labs at -n 9pm: na 133 cl 93 bun 69 gluc 106 k 7.6 co2 21.6 cr 3.1 ag 19 ca 7.1 alb 3.1 ap 147 ast 243 alt 66 tbili 1.68 repeat k 5.1 abg (15l) 7.44/32/80 cbc: 47.6>41.7<454 diff: 86n/8band/1lymp/5mono inr >10 ptt 73.9 03:13am wbc-39.3*# rbc-5.27 hgb-12.8* hct-38.8* mcv-74*# mch-24.3* mchc-33.1 rdw-16.7* 03:13am plt smr-high plt count-485* 03:13am neuts-82* bands-10* lymphs-5* monos-2 eos-0 basos-1 atyps-0 metas-0 myelos-0 nuc rbcs-1* 03:13am pt-127.4* ptt-90.2* inr(pt)-17.9* 03:13am glucose-106* urea n-72* creat-3.2*# sodium-136 potassium-5.0 chloride-96 total co2-24 anion gap-21* cxr - ap (-n): wedgeshaped pleural opacities in rll and lll with air-bronchogram on lul, pulmonary vessel engorgement. ct chest - impression: findings compatible with multifocal pneumonia. multiple pathologically enlarged mediastinal lymph nodes at multiple stations echo tte - the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 60-70%) there is no ventricular septal defect. the right ventricular cavity is dilated with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the findings are similar. impression: no obvious vegetations seen 8:40 am sputum source: expectorated. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. sparse 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. streptococcus pneumoniae. rare growth. staph aureus coag +. sparse growth 2nd type. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. penicillin sensitivity available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | streptococcus pneumoniae | | staph aureus coag + | | | ceftriaxone----------- <=0.06 s clindamycin----------- =>8 r <=0.25 s erythromycin---------- =>8 r <=0.06 s <=0.25 s gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r 1 s 0.25 s oxacillin------------- =>4 r <=0.25 s penicillin g---------- =>0.5 r <=0.06 s rifampin-------------- <=0.5 s tetracycline---------- 2 s <=1 s trimethoprim/sulfa---- <=0.5 s <=0.5 s <=0.5 s vancomycin------------ <=1 s <=1 s brief hospital course: in brief, the patient is a 54 year old man with chronic upper extremity ulcers of unknown etiology (vasculopathy), interstitial lung disease, recurrent pulmonary embolism who presented with hypoxia, altered mental status, acute renal failure found to have multilobar pneumonia. 1) hypoxia: the patient presented with bilateral infiltrates, fever, and markedly elevated wbc count with bandemia and imaging was consistent with a multilobar pneumonia. sputum cultures revealed mrsa. he was empirically started on cefepime and vancomycin then transitioned to oral bactrim and is to complete a 7 day course. given his markedly elevated inr it was thought unlikely for him to have had a recurrent pe. given the wedge-shaped opacities on the chest ct, he had a tte to evaluate his right sided heart valves which showed no signs of vegetation. his oxygenation improved steadily, but note should be made that given his marked vasculopathy his pulse-oximetry should be measured from either his forehead or ear instead of his fingers. his ct appeared to show a tracheo-esophageal fistula but on review of the images this was thought to unlikely. he passed a bedside and video-swallowing eval and showed no sign of aspiration. following discharge he should have a follow-up appointment in pulmonary clinic to confirm resolution of his infiltrates, if his infiltrates do not entirely resolve, consideration should be made for lung biospsy to further evaluate his more chronic respiratory symptoms. # altered mental status: the patient presented with non-focal neurologic exam and following commands appropriately. the likely cause was the significant hypoxia likely exacerbated by his pain medicine regimen. # coagulopathy: the patient presented with a markedly elevated inr likely induced by coumadin. he showed no evidence of acute bleeding or consumptive coagulopathy. his inr was reversed on arrival but was brought back to therapeutic after he stabilized. # acute renal failure: the patient presented in non-oliguric renal failure. this was likely of pre-renal etiology given minimal protein in the urine and unremarkable urinalysis. his creatinine normalized rapidly with fluid repletion and treating his pneumonia. # chronic pain: his pain medicines were decreased on admission given his altered mental status then gradually re-introduced as his pneumonia improved. # hypothyroidism: there were no acute issues and he remained on his home dose of levothyroxine. medications on admission: warfarin 5 mg daily pantoprazole 40 mg q24h gabapentin 600 mg q8h oxcarbazepine 300 mg daily oxycodone 80 mg q8h nifedipine sr 30 mg daily levothyroxine 75 mcg daily fluticasone-salmeterol 250-50 tiotropium bromide 18 mcg daily docusate sodium 100 mg bisacodyl 5-10 mg daily (daily) as needed. albuterol sulfate neb q6h:prn oxycodone 30 mg tablet q6:prn aloe vesta 2-n-1 protective daily discharge medications: 1. warfarin 1 mg tablet sig: six (6) tablet po once a day. :*30 tablet(s)* refills:*0* 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 3. gabapentin 600 mg tablet sig: one (1) tablet po every eight (8) hours. 4. oxcarbazepine 300 mg tablet sig: one (1) tablet po daily (daily). 5. oxycontin 80 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po every twelve (12) hours. 6. oxycodone 30 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po daily (daily) as needed. 8. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 9. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 10. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 11. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 4 days. :*8 tablet(s)* refills:*0* 12. robitussin cough-congestion 10-200 mg/5 ml syrup sig: po every six (6) hours as needed for cough. :*1 bottle* refills:*0* 13. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po once a day. 14. advair diskus 250-50 mcg/dose disk with device sig: one (1) inh inhalation twice a day. 15. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) nebulization inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. aloe vesta 2-n-1 protective ointment sig: one (1) topical once a day: apply to extremities. 17. outpatient lab work inr check . please fax results to pcp, ., f. discharge disposition: home with service facility: discharge diagnosis: pneumonia discharge condition: hemodynamically stable discharge instructions: you were admitted into the hospital for treatment of your pneumonia. you had a severe pneumonia and you were treated initially in the intensive care unit with vancomycin. you have been transitioned to bactrim oral antibiotics. you are to continue on bactrim twice daily and you are to complete a 7 day course. . please continue with your remaining mediacations as instructed. . if you experience worsening cough, fevers > 101, shortness of breath, abdominal pain, nausea, vomiting, diarrhea or any other concerning symptoms then please call your doctor or report to the nearest emergency room. followup instructions: please follow up with your pcp . within weeks. please call for your appointment . md procedure: venous catheterization, not elsewhere classified diagnoses: abnormal coagulation profile acute kidney failure, unspecified unspecified viral hepatitis c without hepatic coma infection with microorganisms resistant to penicillins acute respiratory failure methicillin susceptible pneumonia due to staphylococcus aureus hypoxemia dehydration ulcer of other part of lower limb chronic ulcer of other specified sites generalized pain 

Answer: The patient is high likely exposed to