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: keflex / erythromycin base / fentanyl / morphine / linezolid / dilaudid / heparin agents attending: chief complaint: hypotension, lethargy major surgical or invasive procedure: s/p picc line () s/p egd x 2 (, ) s/p ileoscopy () s/p tunneled dialysis catheter placement () history of present illness: 66f with hx of copd s/p trach, esrd on hd, sacral decubs, hx of mrsa, serratia bacteremia and cdiff who presents from home with lethargy. per pt's family, she has been more lethargic and hyperglycemia over the past month and a half. her son states that her blood sugars typically run between 150-200 but over the past 4 weeks, her sugars have been as high as 500. her physician has been increasing her nph and finally put her on glargine recently but her sugars remain uncontrolled. also, pt's family states that at baseline, she follows some commands and is able to ask for water and ice chips. lately, she has not been very responsive which is typical for when she is infected. shje was recently admitted to hospital (d/c'd on ) with similar symptoms and she was diagnosed with endocarditis (records not available). she was discharged on zosyn and tygacil. these were stopped 2 weeks ago. they also note that she has been having low grade fevers to 100 at home with normal sbp in the 90s-100s. also, she has been having clots in both her colostomy and peg tube. pt's family states that pt has had no specific complaints. no increased stool output, no complaints of abd pain. . on arrival to the er, her sbp was in the 70s-80s with hr in the 110s. she improved to 100-110 with 1l of ns. after discussion with the family, the er decided not to call a code sepsis. she was given cefepime and vanc and admitted to the micu. past medical history: 1. diastolic heart failure 2. esrd on hd 3. aortic valve replacement (st. , on coumadin 4. paroxysmal a fib 5. thrombocytopenia 6. copd, s/p trach 7. mrsa + sternotomy wound infxn ~2year ago. treated with ~1years of iv vanc at (per daughter) 8. mrsa bacteremia s/p 4 weeks of vanc 9. h/o pea arrest 10. left parietal cva . persistent hyperphos 12. type ii dm 13. recent serratia bacteremia (as above) 14. anemia of chronic dz 15. chronic sacral decub 16. necrotic right toes social history: hcp: , . family spokesperon: (daughter) 8 children who live in the area and are involved in pt's care family history: non-contributory physical exam: temp 98.8, bp 108/48, hr 110-120, o2 100% vent: ac 450 x 16 (breathing at 24) x 5 x 50% abg: 7.29/33/238 gen: nad, does not respond to voice, slightly responsive to pain heent: pupils 5mm -> 2mm; mmm neck: jvd not appreciated cv: irreg irreg, metallic click chest: clear other than bronchial breath sounds at lul posteriorly abd: peg and colostomy in place; obese; no bowel sounds heard; nontender ext: 1+ pitting edema bilaterally; dp pulses not palpable skin: large stage iv sacral ulcer with several surrounding ulcers; largest part of ulcer with black base and deep to bone; also with ulcers on posterior lower extremities and on heels; right toes with necrosis neuro: perrl, +corneal reflex, no reflexes, no response to babinski; increased tone in upper ext, l>r pertinent results: 09:56pm glucose-291* lactate-4.0* na+-134* k+-3.7 cl--97* 07:46pm glucose-321* lactate-4.4* 07:45pm glucose-327* urea n-129* creat-4.2* sodium-130* potassium-6.5* chloride-91* total co2-17* anion gap-29* 07:45pm cortisol-40.6* 07:45pm wbc-23.3* rbc-3.14* hgb-11.1* hct-34.1* mcv-109*# mch-35.3*# mchc-32.5 rdw-20.5* 07:45pm neuts-78* bands-8* lymphs-4* monos-9 eos-0 basos-0 atyps-0 metas-0 myelos-1* nuc rbcs-4* 07:45pm hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-occasional polychrom-2+ spherocyt-1+ ovalocyt-occasional burr-occasional 07:45pm plt count-307 07:45pm pt-38.6* ptt-40.1* inr(pt)-4.3* . . 04:03am blood wbc-4.1 rbc-3.20* hgb-10.3* hct-29.5* mcv-92 mch-32.2* mchc-34.9 rdw-18.5* plt ct-18* 04:03am blood plt smr-rare plt ct-18* 04:03am blood pt-23.3* ptt-55.3* inr(pt)-2.3* 04:03am blood glucose-226* urean-29* creat-2.0* na-149* k-3.4 cl-112* hco3-18* angap-22* 03:12am blood alt-5 ast-35 ld(ldh)-190 alkphos-294* amylase-12 totbili-4.2* 04:03am blood calcium-8.7 phos-2.5* mg-1.7 03:21pm blood hbsag-negative hbsab-positive hbcab-negative hav ab-positive igm hbc-negative igm hav-negative 03:12am blood digoxin-1.0 . 8:00 pm blood culture received at 10:10pm. **final report ** aerobic bottle (final ): reported by phone to , rn cc6b @ 1624 on . enterococcus faecium. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecium | ampicillin------------ =>32 r linezolid------------- 4 i penicillin------------ =>64 r vancomycin------------ =>32 r anaerobic bottle (final ): enterococcus faecium. identification and sensitivities performed from aerobic bottle. . . 1:55 am sputum site: endotracheal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. identification requested on negativer rods by dr. . pseudomonas aeruginosa. moderate growth. amikacin 16mcg/ml =s. minimal inhibitory concentration:. sensitivity performed by . klebsiella pneumoniae. moderate growth. trimethoprim/sulfa sensitivity testing available on request. amikacin 16mcg/ml = s. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. acinetobacter baumannii. moderate growth. trimethoprim/sulfa sensitivity testing available on request. "note, for amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". amikacin 16 mcg/ml = s. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | klebsiella pneumoniae | | acinetobacter baumannii | | | ampicillin/sulbactam-- =>32 r 4 s cefazolin------------- =>64 r cefepime-------------- 8 s r 32 r ceftazidime----------- 8 s r =>64 r ceftriaxone----------- r cefuroxime------------ 32 r ciprofloxacin--------- =>4 r =>4 r =>4 r gentamicin------------ 8 i =>16 r =>16 r imipenem-------------- 8 i 2 s 8 i levofloxacin---------- =>8 r =>8 r meropenem------------- 4 s <=0.25 s piperacillin---------- 16 s piperacillin/tazo----- 16 s =>128 r tobramycin------------ <=1 s =>16 r 4 s . . : cxr findings: right picc line, left dialysis catheter and tracheostomy tube remain in place. compared to the prior study, there is new increased density in the left upper lung zone, which could be a developing pneumonia. extremely subtle increase in density is seen adjacent to the right hilar region, which could relate to early pulmonary edema. however, the pulmonary vascular markings are not significantly distended. right effusion is again demonstrated. impression: new airspace finding in the left upper lung zone, possibly in the right mid lung zone. continued followup is recommended. . abdominal a-gram: impression: 1. nonselective aortography and selective superior mesenteric artery arteriogram demonstrate no evidence of active gastrointestinal bleeding. diffuse atheromatous disease was noted. 2. selective catheterization of the inferior mesenteric artery was unsuccessful, likely due to severe atherosclerotic disease at its origin as shown on a previous ct scan. 3. endoscopy recommended to better clarify origin of bleeding. . ct head: impression: no acute intracranial hemorrhage or change from the prior examination. . mr : impression: no definite evidence of osteomyelitis of the sacrum. subtle increased signal within the coccyx could be secondary to partial volume averaging from the adjacent decubitus ulcer. moderate spinal stenosis at l4-5 level. brief hospital course: 66f with chronic trach and peg, s/p cva in with residual weakness who presents from home with lethargy and hypotension. . # sepsis: on admission, wbc elevated to 23 with 8% bands and lactate of 4.4. patient with hx of c diff, serratia and mrsa bacteremia in the past. during a previous admission, pt had mrsa bacteremia but no source was identified. no hx of diarrhea. blood, sputum cultures sent. pt is anuric so no urine culture. patient however with multiple sources of infection, including sacral decub ulcers, dry gangrene in both feet, tracheostomy and g-tube insertion sites. pt sx's initially improved dramatically with supportive therapy. cultures returned pseudomonas from sputum and begun on meropenem on . ct + mri of sacral and posterior-tibial decubs showed no evidence of osteomyelitis. patient initially failed -stim test and completed a five day course of stress dose steroids. regarding sacral decub ulcers, plastics was consulted and did not feel there was any role for surgical intervention. during admission, patient with multiple positive cultures including the following: sputum on growing pseudomonas and gnr; sputum on , , growing pseudomonas and gnr; sacral decubitus ulcer swab on growing gnr, pseudomonas, coag positive staph aureus, and klebsiella; sputum culture on and growing klebsiella, pseudomonas; blood culture on growing enterococcus faecium (vre but sensitive to linezolid). patient has been treated with tobramycin and zosyn for double coverage of pseudomonas in sacral decubitus ulcers, linezolid for mrsa and vre, and levofloxacin for chronic aortic abscess with serratia. patient's hd catheter was removed when patient was found to have vre. . patient also with hx of aortic annular abscess with serratia and ? of endocarditis at and is chronically treated with levoquin. vasc performed a partial amp/debridement of the l great toe in the setting of dry gangrene. wound cultures from the tissue returned pseudomonas as well which showed resistance to meropenem. vasc surgery recommended amputation with bka due to gangrneous toes bilaterally. family refused intervention. . pt had a recurrent episode of vre in her blood and a pna with psuedomonas and klesiella. this was again treated with meropenem and amikacin for a 14 day course. she was also started on daptomycin for recurrent vre in her blood for a 14 day course. . # lethargy: patient with lethargy throughout her course, likely secondary to patient's sepsis. head ct was negative for any intracranial hemorrhage or mass. this improved and pt was at her baseline at time of discharge. . # resp: s/p trach, on vent at home with settings of assist control 450x22xpeep of 5x60%. pt. remained mostly on home vent settings throughout hospital stay. oxygenating well on fio2 of 60%. she had her peep increased to 8 increased pleural effusions due to volume resuscitation during bouts of sepsis/gi bleed. also, during her acute gi bleed, her rate was increased to help offset a lactic acidosis that occured the large amounts of blood products she received. other than this her vent settings have remained stable. will likely be able to decrease her fio2 over time after her pneumonia completely resolves. trach is 7.0 extra long shiley. . # cv: ** ischemia: ekg nml ** rhythm: paf; on dilt for rate control. continue amio and digoxin. pt was taken off all anticoagulation due to recurrent gi bleeding. cardiology consulted for risk of no anticoag with mechanical valve. risk of thrombus is approx 10% per year, however pt had large gi bleed on any anticoagulation. due to liver failure, pts inr has remained elevated to 2.0 throughout admission. ** pump: ef 55% on echo, diastolic dysfxn. . # esrd on hd: during this admission, patient was initially on hemodialysis and was converted for a short time to cvvhd. however, once patient's renal function and hemodynamics became more stable, patient should be continued on hemodialysis per home regimen. . # anemia: baseline hct of 29-30. during this admission, patient became supratherapeutic on coumadin and heparin and developed increased bleeding, including vaginal bleeding, skin tears, and sacral ulcers. pelvic us demonstrated thickened endometrial stripe. ob-gyn was consulted and did not suggest further work-up given that patient was unlikely to receive any further treatment. patient's coumadin and heparin drip have been held while concern for active bleeding. pt then had active gi bleeding and all anticoag has been held for recurrent gib while on anticoagulation. . # gib: pt had bright red blood per ostomy and gi service was consulted. pt found to have petecial lesion in residual colon, no active bleeding. egd was negative. attempted to restart anticoagulation however pt continued to have gib when on heparin. on one occasion, a bleeding vessel was found at the stomal site and a stitch was placed by surgery, with no recurrent bleeding from that vessel. decision made with gi and cardiology to hold anticoagulation. . # lactic acidosis: pt was found to be hypotensive to the 50s-60s several times during her hospital course. an arterial line was placed for better monitoring and revealed a difference in cuff pressure of 30 points. lactate was elevated to 10, which was attributed to linezolid. this was discontinued and she was started on daptomycin for vre bacteremia. she should not receive linezolid again and it was added to her allergy list. . # dm: patient with very poorly controlled blood glucose at home. patient's blood glucose was managed during this hospitalization with the help of . she was placed on an insulin drip during her intermittent sepsis, as her sugars were difficult to control. prior to discharge, her insulin regimen was transitioned to glargine at 7 untis qam and an agressive insulin sliding scale. . # thrombocytopenia: pt had progressive thrombocytopenia throughout admission. hep ab neg. felt to be 2/2 pts extensive medical illnesses and broad spectrum abx. no furhter intervention at this time. dic labs normal. pt did not require plt transfusion. team was notified after patient was discharged that heparin dependent antibody sent on had come back as positive. case management was notified to let the patient's dialysis service and home nursing agency know that the patient should not receive heparin in any form. . # wound care: pt has large sacral decub and multiple skin tears skin breakdown. wound care followed throughout admission. . # social: multiple family meetings were held with medical, nursing, social work, case management, gi and renal consultants throughout this admission where the medical staff made it clear to the family that the patient is dying and that we would recommend comfort measures at this point. the health care proxy refused to convert care to comfort and wanted to continue with aggressive measures. ethics and palliative care consulted during this admission and fmaily refused to talk to them. . # code: already intubated, no shocks, no compressions. dnr. . medications on admission: * flagyl 500mg tid (started 2 days ago) * levaquin 250mg qod (lifelong for aortic annular abscess) * prozac 40mg qd * nephrocaps qd * nexium 40mg qd * amiodarone 400mg qd * phospho-soda 5ml qd * midodrine 5mg tid * lactulose 5ml 4x per day * coumadin 3mg qd * reglan 5mg once a day * lopressor 6.25mg (once a day on hd days) * digoxin 0.0625 qod * ativan 0.5mg qid * zofran 4mg before hd * glargine 70u * riss * albuterol inh * atrovent inh * flovent inh discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 8-12 puffs inhalation q6h (every 6 hours). disp:*qs 1 month * refills:*3* 2. ipratropium bromide 17 mcg/actuation aerosol sig: 8-12 puffs inhalation q6h (every 6 hours). disp:*qs 1 month * refills:*3* 3. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*qs 1 month * refills:*2* 4. fluoxetine 20 mg/5 ml solution sig: one (1) 10ml po daily (daily). disp:*qs 1 month 10ml* refills:*3* 5. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). disp:*15 tablet(s)* refills:*3* 6. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. disp:*qs 1 month * refills:*2* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. disp:*60 capsule(s)* refills:*2* 8. amiodarone 200 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*3* 9. midodrine 5 mg tablet sig: 2.5 tablets po tid (3 times a day). disp:*225 tablet(s)* refills:*2* 10. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). disp:*qs 1 month * refills:*2* 11. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed for skin care. disp:*qs 1 month * refills:*2* 12. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 13. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 14. picc line care picc line care per protocol 15. tube feeding supplies 16. tracheostomy supplies 17. tracheostomy 7.0 extra-long shiley trach 18. ventilator settings assist control tidal volume: 450cc respiratory rate: 22 fio2: 60% peep: 8 19. insulin syringe syringe sig: one (1) syringe miscell. four times a day as needed for insulin administration: please administer insulin per sliding scale. disp:*qs syringe* refills:*6* 20. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po once a day. disp:*qs mg* refills:*6* 21. lantus 100 unit/ml solution sig: seven (7) units subcutaneous qam. disp:*qs units* refills:*6* 22. daptomycin 500 mg recon soln sig: four y (450) mg intravenous q48h (every 48 hours) for 14 days. disp:*3150 mg* refills:*0* 23. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q8h (every 8 hours) for 2 days. disp:*3000 mg* refills:*0* 24. epoetin alfa 4,000 unit/ml solution sig: 8000 (8000) units injection qmowefr (monday -wednesday-friday). disp:*qs units* refills:*6* 25. demerol 50 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*120 tablet(s)* refills:*0* 26. ativan 0.5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for agitation. disp:*120 tablet(s)* refills:*0* 27. alcohol pads pads, medicated sig: one (1) pad topical every 6-8 hours as needed for insulin administration. disp:*120 pads* refills:*6* 28. lancets misc sig: one (1) lancet miscell. every hours as needed for glucose monitoring. disp:*180 lancets* refills:*6* 29. insulin needles (disposable) needle sig: one (1) needle miscell. every 4-6 hours as needed for insulin administration. disp:*120 needles* refills:*6* 30. tube feeds nepro full strength + beneprotein 25 gm/day; 40 ml/hr; check residuals q4h, hold feeding for residual >=100 ml; flush w/200 ml water q4h 31. insulin regular human 100 unit/ml solution sig: as directed per sliding scale injection four times a day: as per sliding scale. . disp:*qs one month qs* refills:*2* discharge disposition: home with service facility: critical care systems discharge diagnosis: copd s/p trach ventilator dependent diastolic chf aortic annular abscess esrd on hemodialysis gi bleed paroxysmal atrial fibrillation enterococcus bacteremia sacral decubitus ulcer gangrenous toes discharge condition: stable discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: npo with tube feeds only . please continue your home ventilator at tidal volume 450/respiratory rate 22/fio2 60%/ peep 8. please continue tube feedings at home. please call your primary care physician 911 with fevers, pain, difficulty with ventilation or other concerning symptoms. followup instructions: please call your primary care physician . to schedule follow-up. hemodialysis mwf procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other endoscopy of small intestine enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis venous catheterization for renal dialysis closed [endoscopic] biopsy of bronchus aortography endoscopic control of gastric or duodenal bleeding arteriography of other intra-abdominal arteries incision with removal of foreign body or device from skin and subcutaneous tissue nonexcisional debridement of wound, infection or burn transfusion of packed cells replacement of tracheostomy tube replacement of tracheostomy tube transfusion of other serum transfusion of platelets endoscopy of large intestine through artificial stoma replacement of tube or enterostomy device of small intestine replacement of tube or enterostomy device of small intestine replacement of tube or enterostomy device of small intestine replacement of tube or enterostomy device of small intestine injection or infusion of oxazolidinone class of antibiotics diagnoses: anemia in chronic kidney disease end stage renal disease acute posthemorrhagic anemia acute and subacute necrosis of liver acquired coagulation factor deficiency unspecified septicemia severe sepsis chronic airway obstruction, not elsewhere classified atrial fibrillation hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease pneumonia due to pseudomonas cellulitis and abscess of leg, except foot long-term (current) use of insulin septic shock pressure ulcer, other site pressure ulcer, lower back late effects of cerebrovascular disease, hemiplegia affecting unspecified side acute and subacute bacterial endocarditis infection and inflammatory reaction due to other vascular device, implant, and graft anticoagulants causing adverse effects in therapeutic use pressure ulcer, heel hemorrhage of gastrointestinal tract, unspecified diabetes with other specified manifestations, type ii or unspecified type, uncontrolled unspecified intestinal obstruction pneumonia due to klebsiella pneumoniae gangrene chronic diastolic heart failure chronic respiratory failure other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms attention to tracheostomy infection and inflammatory reaction due to cardiac device, implant, and graft chronic osteomyelitis, ankle and foot other colostomy and enterostomy complication pressure ulcer, hip postmenopausal bleeding 

Answer: The patient is high likely exposed to