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: shortness of breath major surgical or invasive procedure: intubation tracheostomy internal jugular central line placement bilaterally history of present illness: 52 y.o. male with morbid obesity, type ii diabetes, obstructive sleep apnea and chf who contact his pcp this morning to say that he was not feeling well. at that time he mentioned feeling increasingly short of breath for approximately 3 days with generalized malaise. it is unclear whether he was requiring increased oxygen. at baseline he uses 2-5 l nc and is prescribed cpap but is non-compliant. his pcp called an ambulance to transport him to the ed. of note the patient was recently admitted to the micu on when he presented with hypoxia (80% on ra) and required bipap. at that time it was thought that his hypoxia was secondary to his obesity related lung disease. he was extremely aggitated secondary to his hypercarbia and signed himself out of the icu ama after only a few hours. . in the ed his vitals were temp 99.4, hr 88, bp 138/88, rr 36 with an o2 sat of 88% on ra. he was noted to be extremely aggitated and had difficulty responding to questions. he denied chest pain, fevers, chills, cough, sputum production or increasing oxygen requirement. he reported pain in abdomen but was unable to describe the pain further and points to a site beneath his panus. he denies nausea, vomiting, diarrhea, brbpr. he denied any dysuria or increased urinary frequency. he did report increasing "shakiness" which worsened with his worsening respiratory status. in the ed he received one dose of ativan 0.5 mg and was placed on bipap with an fio2 of 0.5, pressure support of 15 and a peep of 5. . on arrival to the icu patient was increasingly aggiated and his o2 sats were in the low 90s on bipap with 100% fio2. shortly on arrival the patient desatted to the low 80s requiring emergent intubation. abg taken shortly prior to intubation was ph 7.07, pco2 141, o2 122. past medical history: past medical history: 1. morbid obesity. 2. hypertension. 3. obstructive sleep apnea on cpap 12 with 2 liters of supplemental o2 (not currently using). on 5l nc at home. 4. insulin-dependent diabetes (followed at . seen by an ophthalmologist once a year. he has not seen a podiatrist in over two years. : hemoglobin a1c 8.6, urine albumin to creatinine 31.6). 5. chf (ef indeterminate on most recent echo). 6. polycythemia. 7. ? h/o copd (he has never had pulmonary function testing). 8. degenerative disc disease. 9. diabetic neuropathy. 10. venous stasis/leg ulcers. 11. right knee with torn cartilage (?meniscal injury). 12. history of left hip pain status post fall one year ago using lidoderm patches. 13. hyperlipidemia (last cholesterol : tc 157, tg 238, hdl 45, ldl 76) . past surgical history: 1. status post splenectomy secondary to motor vehicle accident (he is unclear of his vaccination status, he is not sure when he last received the pneumovax). 2. status post vascular repair of his right groin (details unclear). social history: he is married, but is estranged from his wife. works part-time for a property management company. he walks with a cane at baseline he denies current tobacco use. he smoked briefly for 2 years, however quit over 10 years ago. he drinks etoh occasionally. he has never been a heavy drinker. he denies illicit drug use. family history: family history: his mother has hypertension. his father died from complications of diabetes and hypertension. he did not have coronary artery disease. he has four brothers, all which are healthy. he has 2 boys aged 21 and 27, both healthy. his uncle is status post heart transplant (details unknown). physical exam: vs t: 98.4 p 101 bp: 138/88 rr 25 o2sat 94% on bipap w/pressure support of 15 with a peep of 5 and fio2 100% general: aggitated, confused, oriented to self, hospital heent: perrl, eomi, oropharynx clear neck: neck supple, unable to assess jvp secondary to body habitus pulmonary: distant breath sounds, no wheezes, rales, ronchi appreciated cardiac: rrr, distant, no murmurs appreciated abdomen: obese, erythematous lower panus, complains of tenderness but extremities: wwp, 2+ pulses, chronic venous stasis changes bilaterally, 1+ edema bilaterally, no clubbing or cyanosis neurologic: + asterixis, otherwise non-focal pertinent results: labs: 07:48pm blood wbc-13.0* rbc-6.33* hgb-18.4* hct-58.7* mcv-93 mch-29.1 mchc-31.4 rdw-15.7* plt ct-266 03:48am blood wbc-10.9 rbc-5.58 hgb-15.7 hct-49.1 mcv-88 mch-28.1 mchc-32.0 rdw-16.0* plt ct-264 03:50am blood wbc-12.6* rbc-5.15 hgb-14.9 hct-45.4 mcv-88 mch-28.9 mchc-32.7 rdw-16.1* plt ct-249 04:23am blood wbc-11.3* rbc-4.76 hgb-13.7* hct-41.8 mcv-88 mch-28.8 mchc-32.8 rdw-15.9* plt ct-297 03:00am blood wbc-17.0* rbc-4.75 hgb-13.7* hct-41.8 mcv-88 mch-29.0 mchc-32.9 rdw-15.7* plt ct-365 03:01am blood wbc-14.7* rbc-4.66 hgb-13.5* hct-40.8 mcv-88 mch-28.9 mchc-33.0 rdw-15.9* plt ct-521* 04:00am blood wbc-15.5* rbc-4.78 hgb-13.4* hct-41.5 mcv-87 mch-28.1 mchc-32.4 rdw-16.1* plt ct-534* 04:36pm blood hct-41.0 04:10am blood wbc-17.0* rbc-4.72 hgb-13.5* hct-41.4 mcv-88 mch-28.5 mchc-32.5 rdw-16.0* plt ct-430 04:15pm blood hct-40.1 06:53pm blood hct-37.8* 03:32am blood wbc-16.8* rbc-4.70 hgb-13.6* hct-40.9 mcv-87 mch-28.9 mchc-33.3 rdw-16.1* plt ct-342 03:27am blood wbc-16.2* rbc-4.71 hgb-13.6* hct-40.0 mcv-85 mch-28.9 mchc-34.0 rdw-16.0* plt ct-420 07:48pm blood plt smr-normal plt ct-266 03:20am blood plt ct-239 02:27am blood plt ct-309 03:01am blood plt ct-521* 02:46am blood plt ct-438 02:30am blood plt ct-345 07:48pm blood glucose-159* urean-18 creat-0.9 na-141 k-5.2* cl-100 hco3-31 angap-15 03:20am blood glucose-158* urean-32* creat-1.9* na-137 k-4.7 cl-97 hco3-32 angap-13 03:50am blood glucose-123* urean-56* creat-2.8* na-134 k-4.6 cl-98 hco3-27 angap-14 04:50am blood glucose-208* urean-75* creat-3.1* na-137 k-5.4* cl-101 hco3-25 angap-16 05:53pm blood glucose-132* urean-59* creat-2.2* na-144 k-4.6 cl-108 hco3-25 angap-16 03:01am blood glucose-170* urean-47* creat-1.8* na-147* k-4.8 cl-111* hco3-28 angap-13 02:41am blood glucose-135* urean-44* creat-1.3* na-144 k-4.5 cl-107 hco3-28 angap-14 03:00am blood glucose-171* urean-37* creat-1.1 na-142 k-4.9 cl-104 hco3-28 angap-15 10:45am blood glucose-142* urean-33* creat-1.3* na-139 k-4.1 cl-99 hco3-30 angap-14 03:32am blood glucose-126* urean-23* creat-1.1 na-138 k-4.4 cl-98 hco3-31 angap-13 03:27am blood glucose-149* urean-27* creat-1.1 na-140 k-4.2 cl-100 hco3-30 angap-14 02:30am blood pth-13* 02:15pm blood cortsol-11.3 02:56pm blood cortsol-30.5* 03:27pm blood cortsol-35.4* 11:34pm blood freeca-1.27 02:12pm blood freeca-1.30 . micro: 12:22 am urine source: catheter. **final report ** urine culture (final ): mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination. enterococcus sp.. >100,000 organisms/ml.. predominating organism interpret results with caution. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ <=1 s . 5:12 pm staph aureus screen source: nasal swab. **final report ** staph aureus screen (final ): staph aureus coag +. sparse growth. oxacillin sensitivity performed by agar screen. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | oxacillin------------- r . 4:20 am sputum site: endotracheal **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): sparse growth oropharyngeal flora. 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. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. staph aureus coag +. 2nd type. 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. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | staph aureus coag + | | erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r =>8 r oxacillin------------- =>4 r =>4 r penicillin------------ =>0.5 r =>0.5 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- <=1 s <=1 s vancomycin------------ <=1 s <=1 s . . imaging: chest (portable ap) 7:10 pm findings: study is markedly limited secondary to underpenetration due to the patient's large body habitus. evaluation of the upper lungs show no gross evidence for focal consolidation or overt pulmonary edema, however the films are limited. the mediastinum is prominent, however, it is unchanged since the , study. there is a catheter overlying the mediastinum that is likely external to the patient. clinical correlation is recommended. . chest (portable ap) 3:45 am findings: upright plain radiograph of the chest. appearance of right internal jugular line and et tube is unchanged in position and appropriate. et tube is approximately 4.4 cm from the tip to the carina. the cardiac silhouette again demonstrates obscuration by a large left-sided pleural effusion. pulmonary vascular congestion appears stable. interval increased aeration of the left lung is identified. impression: et tube stable in position. increased aeration of the left lung with stable pulmonary vascular congestion and left-sided pleural effusion. . portable abdomen 3:17 pm findings: a single portable supine radiograph of the right side of the patient was obtained. there is a small staple seen in the left lower quadrant of this film. due to the poor quality of this film further analysis cannot be made at this time. impression: unable to evaluate for ileus secondary to extremely limited study. . chest (portable ap) 11:37 am impression: 1. new left lower lobe and partial left upper lobe atelectasis, likely due to mucous plugging. these findings were discussed with dr . 2. mild-to-moderate pulmonary edema. . chest (portable ap) 5:19 pm impression: left internal jugular vein central venous line has been retracted to level of left brachiocephalic vein and should be advanced. this was discussed with dr. by telephone at time of interpretation. similar appearance of left lower lobe opacity, representing atelectasis and/or consolidation. left pleural effusion. similar appearance of pulmonary vascular congestion. . chest (portable ap) 7:14 am impression: ap chest compared to through : the technical quality of the examination is limited by patient motion. there has been substantial increase in caliber of multiple vascular structures, particularly both hila and the superior mediastinum suggesting an increase in pulmonary vascular resistance. no edema is seen in the right lung. severe consolidation has progressed on the left accompanied by a probable small left pleural effusion. et tube is in standard placement. nasogastric tube can be traced into the stomach and out of view. a left-sided central venous catheter deviates from the expected course of the left brachiocephalic vein and is presumably in a smaller tributary such as the left internal mammary, or has become extra- vascular. . portable abdomen 1:26 pm single frontal abdominal radiograph: only the central portion of the abdomen is included in the study. two linear radiopaque foreign bodies are seen overlying the right si joint. the prior studies have been of such poor quality that it is not clear whether these are new or old. the bowel gas pattern is nonspecific with air and stool seen in the visualized ascending and transverse colons. no clear evidence of retained needle. . chest (portable ap) 11:50 pm supine portable ap chest: comparison is made to . tracheostomy tube remains in unchanged position. the dobbhoff tube appears to have been advanced slightly and is now in the gastric fundus. assessment of the remainder of the heart and lungs is extremely limited by patient's size. there is equivocal worsening of pulmonary vascular engorgement, which could reflect fluid overload/chf. unchanged collapse/consolidation in the left lower lobe. impression: lines/tubes as above. possible worsening fluid overload/chf. extremely limited study. . chest (portable ap) 2:47 am impression: ap chest compared to through : tracheostomy tube has a standard appearance. feeding tube ends in the upper stomach. mild edema most easily assessed in the right lung has improved since . cardiac silhouette is still large. widening of the mediastinum is probably a combination of fat deposition and vascular engorgement. lateral aspect of the left lower costal pleural surface is excluded from the examination. the other pleural margins are normal. . . brief hospital course: assessment: mr. is a 52-year-old male with morbid obesity, insulin-dependent diabetes, hypertension, obstructive sleep apnea, and chf who presents with increasing shortness of breath for three days. . plan: # hypercarbic respiratory failure: on presentation the patient was experiencing increased respiratory distress and aggitation. initial abg on arrival to the micu revealed a ph of 7.07 with a pco2 of 141. it was thought that his respiratory failure was most likely secondary to obesity related lung disease, obstructive sleep apnea and subsequent co2 retention. the patient has never had formal pulmonary function testing and his baseline pulmonary disease is thus not entirely clear. shortly after arrival to the micu the patient quickly dropped his oxygen saturation to the 80s and became cyanotic. he required emergent intubation. cxr following intubation was suggestive of an infilatrate. he was started on vancomycin and levofloxacin for broad coverage for community acquired pneumonia. his sputum ultimately revealed gram positive cocci in pairs and short chains. on hospital day 4 the patient developed acute renal failure and his urine showed trace positive urine eosinophils. given concern for possible ain his levofloxacin was switched to ceftriaxone and completed a ten day course of antibiotics. the patient required prolonged ventilatory support and during the midst of his stay acquired a mrsa pneumonia that remained refractory to 24 days of vancomycin treatment. thus, he was started on linezolid to complete a 14-day course. given the patients respiratory presentation, it was deemed appropriate that the patient would benefit from a tracheostomy in order to bypass any pharyngeal obstruction contributing to his obstructive hypercapneia. the patient underwent this procedure without complication. after this procedure, the patient was weaning from the vent was difficult as the patient required large amounts of peep in order to avoid desaturation. after institution of the trach, the patient was able to be weaned slowly from the vent from assist control to pressure support ventilation. his sedation was also weaned from continuous fentanyl/midazolam drip to bolus sedation with haldol. he also has had a fentanyl patch placed for sedation wean. the patient was arousable, but still mildly sedated. . #fevers: the patient intermittent spiked fevers while in the icu, and initially it was thought to be due to his pneumonia. his fevers were refractory to a prolonged course of vancomycin, and was subsequently switched to linezolid for better lung penetration. prior to this medication switch the patient underwent a traumatic dobhoff placement in which there was an estimated blood loss of approximately 700 cc of blood. ent packed the right nare and there was damage to his nasal septum. given this insult, and the intermittent fevers, it is likely that the patient may have an occult infection in his sinuses. he was not scanned and it is appropriate that continued fevers may warrant the addition of a penicillin containing antibiotic. . # acute renal failure: on hospital day four the patient developed acute renal failure with elevated creatinine and decreased urine output. urine electrolytes were consistent with prerenal etiology. urine eosinophils were trace positive. it was thought that the most likely etiology was prerenal azotemia secondary to high levels of ventilatory peep decreasing his cardiac output. given the trace urine eosinophils ain was also a consideration. his levofloxacin and proton pump inhibitor were stopped for this reason. as the patient's pressure improved, the creatinine decreased in urine output increased. this picture makes atn secondary to hypotension and increased intraabdominal pressures likely. with decreased peep and increased diuresis the patient's arf resolved and his cr was at baseline upon admission. . # diabetes: the patient is a known insulin dependent diabetic. given his labile blood sugars was consulted and he was placed on an insulin drip to allow calculation of his basal insulin requirement and control of fs while critically ill. upon cessation of the insulin drip, his insulin requirements were adjusted as & his final dosing of lantus upon discharge was 75 lantus , with additional coverage by a humulog sliding scale. . # hypertension: home doses of antihypertensives were held on admission. as his hemodynamics he was restarted on captopril with good effect. he required no other anti-hypertensives prior to admission. . # hyperlipidemia: continued his home dose of lipitor. . # chf: last echo unable to determine ejection fraction. normal bnp, no evidence of exacerbation on chest xray. he was diuresed with lasix 20iv daily to ; he still has evidence of chf on xray. . # prophylaxis: heparin sc, h2 blocker, bowel regimen including intermittent dosing of po narcan to counteract colonic slowing due to opiate dosing. . # fen: tube feeds, ivf boluses to maintain urine output, monitor electrolytes and replete as needed. . # access: r picc . # code status: full code medications on admission: advair 250-50 mcg/dose--1 puff inh twice a day albuterol 90 mcg/actuation--1 puff inh q6hours prn aspirin-81 81 mg--1 tablet(s) by mouth once a day atorvastatin 80 mg--1 tablet(s) by mouth at bedtime cialis 5 mg--1 tablet(s) by mouth prn furosemide 40 mg--1 tablet(s) by mouth twice a day glipizide 10 mg--1 tablet(s) by mouth once a day humalog 100 unit/ml--50 units qac lantus 100 unit/ml--40 units at bedtime lidoderm 5 %(700 mg/patch)--apply to affected area q12hours prn as needed for pain lisinopril 40 mg--1 tablet(s) by mouth once a day oxygen (2-5 l at baseline, cpap for sleep) discharge medications: 1. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 4. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 5. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 6. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 7. heparin (porcine) 5,000 unit/ml solution sig: 1.5 injection tid (3 times a day). 8. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 9. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever. 11. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for fungal infection. 12. sodium chloride 0.65 % aerosol, spray sig: sprays nasal tid (3 times a day). 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 14. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 15. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 16. aluminum hydroxide gel 600 mg/5 ml suspension sig: ten (10) ml po tid (3 times a day). 17. insulin sliding scale see attached sliding scale 18. fentanyl 100 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours): please replace on then begin weaning by 25mcg each patch change. 19. oxymetazoline 0.05 % aerosol, spray sig: one (1) spray nasal prn for 3 days: please use for right nare bleeding. 20. naloxone 1 mg/ml syringe sig: one (1) injection tid (3 times a day) as needed for constipation for 3 days. 21. furosemide 20 mg tablet sig: two (2) tablet po daily (daily). 22. famotidine in normal saline 20 mg/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours). 23. haloperidol 3-5 mg iv q4h:prn agitation 24. lactulose 10 g/15 ml syrup sig: thirty (30) ml po qid (4 times a day) as needed for constipation. 25. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 26. captopril 25 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: hypercarbic respiratory failure s/p tracheostomy . secondary diagnoses: 1. morbid obesity. 2. hypertension. 3. obstructive sleep apnea on cpap 12 with 2 liters of supplemental o2 (not currently using). on 5l nc at home. 4. insulin-dependent diabetes (followed at . seen by an ophthalmologist once a year. he has not seen a podiatrist in over two years. : hemoglobin a1c 8.6, urine albumin to creatinine 31.6). 5. chf (ef indeterminate on most recent echo). 6. polycythemia. 7. ? h/o copd (he has never had pulmonary function testing). 8. degenerative disc disease. 9. diabetic neuropathy. 10. venous stasis/leg ulcers. 11. right knee with torn cartilage (?meniscal injury). 12. history of left hip pain status post fall one year ago using lidoderm patches. 13. hyperlipidemia (last cholesterol : tc 157, tg 238, hdl 45, ldl 76) discharge condition: afebrile, sedated, tolerating tfs discharge instructions: 1. please wean sedation with fentanyl patch and haldol as needed. 2. please return to the ed if the patient has any concerning symptoms including, difficulty breathing or refractory fevers. 3. if the patient becomes febrile, there is likely an infection within his sinuses that could be covered with augmentin. 4. if there is bleeding from the right nare, please use afrin for 3 days. followup instructions: provider: function lab phone: date/time: 2:00 provider: , intepretation billing date/time: 2:00 provider: . / dr. phone: date/time: 2:30 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances other bronchoscopy non-invasive mechanical ventilation percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy transfusion of packed cells control of epistaxis by anterior nasal packing injection or infusion of oxazolidinone class of antibiotics diagnoses: hyperpotassemia acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension infection with microorganisms resistant to penicillins polyneuropathy in diabetes constipation, unspecified other and unspecified hyperlipidemia acute and chronic respiratory failure hypotension, unspecified unspecified sleep apnea morbid obesity methicillin susceptible pneumonia due to staphylococcus aureus rash and other nonspecific skin eruption pneumococcal pneumonia [streptococcus pneumoniae pneumonia] hyperosmolality and/or hypernatremia other and unspecified complications of medical care, not elsewhere classified delirium due to conditions classified elsewhere epistaxis diabetes with neurological manifestations, type ii or unspecified type, uncontrolled foreign body in larynx failure to introduce or to remove other tube or instrument 

Answer: The patient is high likely exposed to