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: codeine / talwin / nafcillin attending: chief complaint: drainage at incision site and fever major surgical or invasive procedure: egd s/p adrenalectomy and splenectomy history of present illness: the patient is a 57 yo female s/p left adrenalectomy and splenectomy on , d/c'd , who returned to the ed on with fever and incision site discharge. past medical history: cushings syndrome, avr , pulmonary avm repair social history: nc family history: nc physical exam: vs- temp 102, hr 88, bp 122/60, rr 28, so2 100 % on 12l fm gen- nad, pleasant heart: rrr, loud sem lungs: cta b/l abd: soft, llq tenderness around incision site, + purulent drainage neuro: axox3 pertinent results: micro: : urine, stool, blood pending : stool negative : urine negative : csf negative : bal-acinetobacter, s only to gent and bactrim and gnr s to bactrim -swab abd wound-enterocccus -urine yeast -urine yeast -bal-1+ yeast, mssa wound: no growth sputum: yeast, gnr ucx-neg -bcx pending -c.diff-neg vre rectal swab: heavy growth. bal: staph aureus and gnr sputum: staph aureus and enterobacter, pan sensitive : blood cx ngtd, urine-neg -urine neg c diff-neg blood:ngtd sputum:enterobacter, staph aureus blood: bottle coag neg staph urine:enterobacter urine: enterobacter blood:neg wound cx: c diff: neg cdiff: neg cath tip: neg mrsa: neg . <b> studies: </b> rads: : cxr: dobbhoff catheter tip is not included on the radiograph. stable widening of the cardiac silhouette with left lower lobe atelectasis and right mid and basilar consolidation. ; ct chest /abdomen and pelvis: 1. patchy ground-glass opacity of the lungs may represent persistent volume overload but is concerning for superimposed pneumonia. 2. small bilateral pleural effusions with persistent collapse of the left lower lobe. 3. no change in a 2 cm soft tissue density adjacent to the sternum, which is of uncertain etiology but may represent a lymph node. 4. stable inflammatory stranding in the splenectomy bed. no fluid collection or abscess identified. ; cxr: . possible acute aortic dilatation or mediastinal hematoma. evaluation should begin with upright chest radiograph. 2. improved severe pulmonary edema. 3. worsening left upper lobe atelectasis. unchanged left lower lobe atelectasis. : mr head w/gd: 1. no abnormal enhancement, intraaxial masses, or abnormal signal to suggest acute infarction. 2. thin dural enhancement along the left parietal lobe that is nonspecific in origin, but could reflect the sequelae of prior trauma (resolved subdural hematoma) or prior lumbar puncture : ct abd/pelv: no significant change in abdominal findings compared to prior study. slight improvement in ground glass opacity consistent with improving edema. interval increase in size of bilateral pleural effusions, greater on the right side. : ct head: limited examination due to patient motion artifact. no acute intracranial hemorrhage. density seen in the right sylvian fissure region may represent prior pantopaque administration or may be due to focal calcification in this area. : us hepatic congestion and gallbladder edema without stones or sludge, though to be due to right sided heart failure cxr-heterogenous diffuse appearance cxr: mod cm, bibasilar consolidation, atelectasis, worse mod pulm edema. cxr: pulm edema rul improved, dense consolidation lll, increased l pleural eff cxr: significantly worsened bilateral pulmonary edema cxr: consolidation and pleural effusions persist cxr: feeding tube below diaphragm. cxr: pulm edema and lll consolidation unchanged. cxr: moderate fluid overload ct abd: negative for collection; ruq u/s: no biiliary pathology; kub: dobhoff in antrum, cxr: patchy right opacity ct head: neg ct : incr standing panc tail; cxr: unchanged patchy asymmetric b opacities, l basilar opacity ct abd: postop changes, bibasilar atelectasis, small b pleural effusions . echo: : ef 70%, symmetric lvh, increased left and right filling pressures, dilated r ventricle. . abx flagyl vanc zosyn fluconazole ceftazidime vanco flagyl cefepime vanc/cefepime flagyl nafcillin levo ceftaz vancomycin cefepime bactrim brief hospital course: the patient was admitted to on with a post operative fever and incision site drainage. she was pan cultured at that time and started on zosyn and flagyl empirically. a cxr at that time demonstrated patchy asymmetric opacities bilaterally, concerning for pneumonia. she refused a cpap mask but accepted 12l face mask oxygen. she is home cpap dependent. she was kept npo. her coumadin was held in case she needed an operation or drainage of an abscess. she was started on 10mg prednisone, as she has known adrenal insufficiency. she tolerated her own cpap machine overnight. a ct scan with contrast showed prominent inflammatory stranding in the left upper quadrant and around the pancreatic tail, most likely representing postoperative changes. there was also a tiny amount of fluid in the splenic fossa, but no drainable collections were identified. there was also bibasilar atelectasis and small bilateral pleural effusions. on hd 2 her diet was advanced. zosyn was discontinued. pt/ot saw her and recommended rehab. we treated her with aggressive pulmonary toilet. a cxr was unchanged. later that night the patient had an acute event- her hr was in the 40's with decreased oxygen saturations and no palpable pulse. chest compressions were begun and she was intubated emergently. she was given epinepherine x 1 and her hr improved to 100. she was saturating 100%. her bp was 100/50. a right ij tlc was placed. she was transferred to the icu. she was sedated with propofol. on hd 3, a chest x-ray demonstrated severe pulmonary edema. cardiac enzymes were cycled and were not elevated. an echocardiogram showed an ef > 55%, moderate tr, and mild-moderate pulmonary htn. she was kept npo. her createnine bumped to 3.4, likely as a result of contrast nephropathy. she was started on vancomycin and zosyn in addition to her flagyl, as she was febrile to 102 and may have gone into septic shock. her tlc was changed to a swann ganz catheter for better monitoring of her fluid status given her new onset arf and pulmonary edema. on hd 4, she was off of levophed and she remained hemodynamically stable all day. endocrinology saw the patient and started hydrocortisone at 100mg q 8 hours for stress dose steroids. the renal service saw her and did not recommend dialysis at this time, but they did recommend limiting her fluid intake. she had only low grade temperatures that day. her uop was 91 for the day. on hd 5, her createnine was up to 4.0. her wbc was 18. a ct of the head was negative. a repeat ct of the abdomen without contrast showed increased inflammatory stranding and possibly a small amount of fluid around the pancreatic tail, bilateral pulmonary effusions (worsening on the right), but no extravasation of prior contrast and no fluid collections around the surgical incision. trophic tube feeds were started. her swann ganz catheter were consistent witha septic picture (svr 358, ci 6.10). she made 355 cc of urine and was afebrile. on hd 6, her createnine was 4.0. her wbc was 15.8. her hct was 23.7. she was transfused 2 units of rbc for blood loss anemia. renal saw her and determined that she was much improved with no need for hd. endocrine put her on 37.5 mg hydrocortisone qid. gi saw her for hematemesisand performed a bedside egd, which was remarkable only for mild antral gastritis. her protonix was increased to 40mg . a heparin drip was started for aortic valve prophylaxis (goal ptt 40-60). she had a tmax of 101. her urine output was 1122 for the day. on hd 7, her swann was changed to a tlc. tpn was started since she was not tolerating her tube feeds. her createnine was down to 2.1. her hydrocortisone was tapered to 25 mg qid. her gi bleeding resolved. she made 520 cc of urine over the course of the day. on hd 8, her createnine was down to 0.9. her wbc was 15 and her hct was 25. her ventillator was weaned to cpap with ps. diuresis was begun with lasix. fentanyl was changed to po oxycodone and lopressor was changed to po as well. on pod 30, the decision was made to continue abx until a 14 day course of vanco/zosyn and 10 day course of flagyl was completed. the patient was taken to the or on pod 31 for an open trach and placement of rsc 3xcvl by thoracic team. lft's were tested and wnl except for elevated alk-phos. patient's foley was replaced based on +ua from pod30, and presence of yeast. on pod32 slow vent weaning was attempted with probable vent rehab being needed. hydrocortisone was dropped to 25q8 and a ruq us was done to because of elevated ap levels, but did not show pathology. patient had tube feeds continued to goal as propofol was gradually weaned with initiation of haldol prn for agitation. attempts to diurese patient were started on pod33 with initiation of prn lasix with good response by patient. patient had propofol weaned off by pod34 with increased haldol requirements and occassional ativan for agitation. patient was transfused for 1unit prbc as hct drifted to 20.8. wbc increased to 29.2 for which ct scan of abdomen was repeated with no new pathology/abscesses identified. patient had continued vent weaning, agitation control, and tf's continued while sources of infection were worked up. patient failed to tolerated vent weaning and was placed on cpap/ps with increased peep/ps levels of 15/15 on pod39. for continued fevers and discover of 3+gnr in sputum and gnr in urine, id was consulted with resultant institution of ceftaz and flagyl for empiric c.diff, and the patients foley/cvl were exchanged. ceftaz was converted to cefepime when urine cultures showed enterobacter resistance to ceftaz. patient maintained this hospital course except for initiation of free water by feeding tube for hypernatremia, and continued peep/psupp wean. patient developed tachypnea and increased wob overnight on for which her peep/psupp was increased and patient was given 1unit prbc. patient improved over the course of until she had a temperature spike to 103.1 (the first following antibiotic course completion) and sputum culture showing gpc pairs/clusters and gn diplocci. because of poor defervesence throughout the patient was empirically started on vanco/cefepime/flagyl. patient noted to have a wbc of 24.3 on and id was reconsulted, who recommended flagyl and nafcillin as cultures from sputum showed mssa. renal was also consulted for isolated bun increase in presence of stable cr with recs c/w high protein tf concentration and steroid use in patient. #. recurrent fevers: patient had recurring fevers during her hospitalization. recent bal from showed no mssa, but gnr and acinetobacter sensitive to bactrim. repeat bal from also showed bactrim-resistant acinetobacter, but no pmn's. vancpmycin course completed for 14 days for mssa pneumonia. sputum cx showed acinetobacter. pt completed 14 day course of bactrim. (d/cd cefepime when sensitivities returned). infectious disease was consulted and when sputum culture grew aztreonam resistant acinetobacter, id felt that it did not need to be treated with gentamycin. she completed a course of 7 days of vancomycin, levofloxacin, fluconazole and flagyl and has been off of these antibiotics several days prior to discharge from the hospital. she has been cdiff negative. repeat ct abdomen showed possible 2 cm organizing fluid collection which was not felt to be an abscess. another ct scan on showed stable inflammatory stranding of splenectomy bed, but no abscess. ir was contact and it was felt that this was not a drainable fluid collection. on , sent wound drainage from left chest wall at jp drain site for amylase, lipase to r/o pancreatitis as cause of persistent wound. wound drainage did have amylase and lipase, however this was felt to be of unclear significance. the wound has since stopped draining. patient also has a soft tissue mass near sternum (possible lymph node) which has not changed in size from 1 year prior and was not fdg avid at that time. bronchoscopy was repeated on and grew acinetobacter. per id consult she repeated another course of will flagyl, levo and vanc for a total of 14 days, last day was . transesophageal echocardiogram was performed on and did not show any valvular vegetations. on tmax over previous 24 hours was 100.5f, on , tmax was 99.8f and on , tmax was 100/0f. her fever curve seems to be continually improving off antibiotics. the source of fevers continue to be unknown. . #. delirium: unclear etiology. suspect steroid psychosis vs steroid withdrawl psychosis vs icu psychosis vs non conculsive seizure. eeg done, no epileptiform activity. ct head showed no acute pathology to account for mental status. mri negative, lp negative. 24 hour eeg negative. mental status had improved, now pt extremely tremulous and tachycardic (likely due to fever). appreciate neuro recs. gradually, klonopin, seroquel, olanzapine were discontinued. she received ativan 1mg iv prn (and received 1-3 times/day depending on her anxiety level. her mental status seems much improved and she no longer seems delerious. . #. respiratory failure: likely due to pneumonia, chf, copd. patient remained on cpap + ps -> : not able to reduce peep from 8. pt tolerated decreased ps of , but was occasionlly tachypneic and ps was increased. her vent was weaned and she was receiving trach mask trials for a couple of hours a day to strengthen her respiratory muscles as it was felt that her difficulty with weaning from the vent was from deconditioning. she was continued on combivent, fluticasone. on attempt trach mask trial again, nif 16, rsbi 60s. . #. anemia: acute drop in hct from 24 to 19 on . guaiac positive brown stool and also with bloody respiratory secretions and blood on bal. had antral gastritis earlier in course. now resolved. pt had hemoccult + vomiting on and . she has been on anti-coagulation for her aortic valve replacement. her hematocrit has remained stable in the low 20's (mainly 22-24). . #. arf: secondary to ain from nafcillin. prior to that had atn from contrast dye. creatinine has improved, urine output has been good and renal function appears back to baseline. . #. cv: patient with no known cad, at home was on atenolol, norvasc and dyazide for bp. weaned clonidine. she was restarted on metoprolol 25mg -> titrated to 50mg on and hr/bp are tolerating this. . #. adrenal insufficiency: s/p adrenalectomy with presumed adrenal insufficiency due to suppression of other adrenal by a cortisol secreting adenoma. now should have adrenal insufficiency regardless based on high doses of cortisol for 2 months. began steroid wean with goal to reach physiologic doses over a very long wean period. per endocrinology a cortisol stim test would not be reliable at this point. was on 25/10/10 of hydrocortisone and changed to equal dose of prednisone 10 qday as pt had at one point in improved mental status on prednisone and wished to determine if mental status would improve. has improved mental status since change with no hemodynamic abn, only increased temp. would favor continuing prednisone and not switching to hydrocortisone. appreciate endocrinology recommendations. pth slightly low at 13, which is likely in response to elevated calcium. 25-hydroxy vitamin d level was slightly low at 18 and vitamin d dihydroxy was pending at time of discharge. . #. hypercalcemia: consulted endocrine and rechecked pth, sent off 25-oh and 1,25-oh vit d. pth was slightly low at 13, 25-oh was slightly low at 18 and vitamin d oh was pending at time of discharge. gave occasional doses of lasix 20 iv once with iv fluids to reduce calcium levels. . #. anticoagulation: for st. jude's valve. heparin drip was transitioned to coumadin and her inr was supratherapeutic at time of discharge. coumadin should be restarted when inr < 3.5. . #. elevated alkaline phosphatase with elevated ggt: trending down. us showed only liver hemangiomas which are not new. be due to secretion from small bowel or pancreas. r uq remains unchanged. appreciate hep recs, considered mrcp to further evaluate liver lesions, and then possibly liver biopsy depending on results of mrcp. however, pt currently not able to hold breath for mrcp (would require paralysis). will hold off on mri for now. . #. ppx: ppi, iv heparin, pneumoboots. . #. fen: tube feeds, repleted electrolytes prn. consulted surgery for peg, but holding until fevers resolve. post pyloric tube placed. . #. access: l picc placed , removed . r double lumen picc placed by ir and no evidence of infection at this site. . #. code: full . #. dispo: to rehab. on discharge to rehab, inr was supratherapeutic at 4.2. coumadin needs to be restarted at rehab when inr < 3.5 (goal 2.5-3.5 for avr). . #. comm: with daughter medications on admission: prednisone 10 daily atenolol 50 daily norvasc 10 daily dyazide 37.5/25 lipitor 20 lasix 40 coumadin 2 daily foradil 12 albuterol 2 puffs tid singulari 10 daily flagyl abmanex 220 daily discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 3. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed. 4. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 5. zinc oxide-cod liver oil 40 % ointment sig: one (1) appl topical prn (as needed). 6. lidocaine hcl 5 % ointment sig: one (1) appl topical prn (as needed). 7. polysaccharide iron complex 150 mg capsule sig: one (1) capsule po daily (daily). 8. acetaminophen 160 mg/5 ml solution sig: po q4-6h (every 4 to 6 hours) as needed. 9. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 10. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 12. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 13. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 14. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 15. pantoprazole 40 mg iv q24h 16. morphine sulfate 1-2 mg iv q4h:prn 17. lorazepam 1 mg iv bid:prn 18. dolasetron mesylate 12.5 mg iv q8h:prn coumadin currently on hold for supratherapeutic inr, should be restarted when inr < 3.5 discharge disposition: extended care facility: - discharge diagnosis: post operative wound infection, cardiopulmonary arrest, blood loss anemia, gastritis, acute renal failure, adrenal insufficency discharge condition: stable discharge instructions: please call or come to the ed with fevers > 101, redness/warmth/drainage/tenderness around your incisions, nausea, vomiting, abdominal pain, shortenss of breath, chest pain, or any other unusual and worrisome event. please continue with your cpapo every night. you may shower and resume regular diet. . you should have you blood checked and coumadin should be restarted when inr < 3.5 for goal 2.5-3.5. followup instructions: please follow-up with your primary care physician upon discharge from rehab. you should have bloodwork checked every other day until inr < 3.5 when coumadin should be restarted (consider 1-2mg coumadin po qhs). inr on day of discharge was 4.2. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances other endoscopy of small intestine insertion of endotracheal tube enteral infusion of concentrated nutritional substances non-invasive mechanical ventilation arterial catheterization temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus pulmonary artery wedge monitoring transfusion of packed cells cardiopulmonary resuscitation, not otherwise specified transfusion of other serum infusion of vasopressor agent diagnoses: abnormal coagulation profile pneumonia due to other gram-negative bacteria acute kidney failure with lesion of tubular necrosis other postoperative infection urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids other specified disorders of pancreatic internal secretion adrenal cortical steroids causing adverse effects in therapeutic use unspecified septicemia iron deficiency anemia secondary to blood loss (chronic) severe sepsis candidiasis of other urogenital sites heart valve replaced by other means cardiac arrest septic shock methicillin susceptible pneumonia due to staphylococcus aureus hyperosmolality and/or hypernatremia delirium due to conditions classified elsewhere hypercalcemia other nonspecific abnormal serum enzyme levels acute gastritis, with hemorrhage 

Answer: The patient is high likely exposed to