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: phenergan attending: chief complaint: cuff leak major surgical or invasive procedure: bronchoscopy with y stenting repeat bronchoscopy history of present illness: 69f hx copd, chf, lung ca s/p rul lobectomy, s/p trach brought from (baintree) resp rehab for ? tracheal misplacement. she was initially admitted to a community hospital in in for chf. she improved and was transferred to (at family's request) for further rehabilitation care. upon arrival to , she was intubated for respiratory distress. after 3 weeks of ventilation, she was admitted to medical center for tracheostomy/peg placement. she did well post-operatively, and was transferred back to for vent weaning. her initial tracheostomy was changed to a bavona on . she did well until one week pta, when she was noted to have increased work of breathing and dyspnea. the mds at decided to change her tracheostomy tube for a longer one. this was done at 4 days pta. postoperatively, she had significant respiratory distress, did not tolerate the vent, and was noted to have lower tidal volumes, hypoxia with saturations to the low 90s, cyanosis and a significant cuff leak. she was started on ceftazidime at her facility for ? pna.she was thus transferred to the for further evaluation/intervention. en route, she was very anxious and given 2mg iv ativan. in the er, she was noted initially to have slight perioral cyanosis with rr 46. her initial abg was 7.39/59/70. she then had an episode of significantly decreased tidal volumes. a flexible bronch was done by dr. in the ed, which showed a posterior tracheal ulceration at the distal end of the , with > 98% occlusion of the distal ostia of the tube by the ulcer wall as well as granulation tissue. the bronchoscope was passed through the obstruction, and the patient's o2 saturations, tidal volumes improved. she had two similar episodes in the ed, which improved with upright positioning, cough, and vocalizations. she had a persistent cuff leak. in th ed, she also recieved vanco 1g iv, ceftazidime 2gm, solumedrol 40mg iv and ativan 2mg iv. past medical history: 1. chf s/p respiratory failure s/p trach 2. copd - o2 dependent 3. nsclc s/p lul lobectomy , s/p chemo (iressa)/xrt, s/p ? pleurodesis 4. dm ii 5. anemia, thrombocytopenia 6. hx recurrent bacteremias 7. hx fungemia 8. s/p l thr 9. s/p cataract surgery . s/p tah 11. paroxysmal afib social history: lived in w/ husband, moved to in to live at . + hx tobacco (uncertain duration). no etoh, illicits. very involved, supportive family. family history: non-contributory physical exam: vs- 97.9 78 104/54 20 96% gen- s/p trach, somnolent but arousable, able to speak despite trach skin - cool, diffuse anasarca w/ ecchymoses heent - perrl, op clear, trach in place at 12cm cor - rrr no m/r/g pulm - coarse bilateral w/ diffuse wheeze and rhonchi abd - obese, nt, nd extr- 4+ lower extremity pitting edema, anasarca neuro - mae x 4, responds to command pertinent results: 01:12pm blood wbc-19.2* rbc-3.46* hgb-10.6* hct-35.3* mcv-102* mch-30.6 mchc-30.0* rdw-19.0* plt ct-246 03:02am blood wbc-13.6* rbc-2.91* hgb-9.1* hct-28.9* mcv-99* mch-31.3 mchc-31.5 rdw-19.6* plt ct-162 03:46am blood wbc-11.7* rbc-3.13* hgb-9.7* hct-30.3* mcv-97 mch-30.9 mchc-31.9 rdw-19.4* plt ct-164 01:12pm blood neuts-82* bands-2 lymphs-10* monos-4 eos-1 baso-0 atyps-1* metas-0 myelos-0 nrbc-2* 01:12pm blood pt-14.2* ptt-21.2* inr(pt)-1.3* 04:00am blood pt-16.7* ptt-21.9* inr(pt)-1.5* 01:12pm blood glucose-244* urean-26* creat-0.7 na-138 k-5.0 cl-97 hco3-31 angap-15 03:46am blood glucose-108* urean-24* creat-0.6 na-145 k-2.9* cl-100 hco3-34* angap-14 03:02am blood calcium-9.4 phos-2.8 mg-2.2 03:46am blood calcium-8.6 phos-2.4* mg-1.9 02:45pm blood type-art temp-37.4 tidal v-500 fio2-50 po2-70* pco2-54* ph-7.39 calhco3-34* base xs-5 intubat-intubated 01:53pm blood type-art temp-37.9 rates-/14 tidal v-600 peep-5 fio2-50 po2-136* pco2-48* ph-7.48* calhco3-37* base xs-11 -assist/con intubat-intubated . cxr: lung volumes are quite low. tracheostomy tube has standard appearance. heart is normal size, shifted slightly to the right. a dense band of radiopacity parallels the minor fissure, which is either a fissural pleural fluid on the right or unusual distribution of atelectasis. just superior to that is an oval region of consolidative lung with an appearance suggesting prior radiation. it could explain right infrahilar consolidation and a vertically oriented that to radiodensity projects lateral to the upper descending thoracic aorta . echo : due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function appears normal (lvef>55%). right ventricular systolic function appears normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve is not well seen. the pulmonary artery systolic pressure could not be determined. the main pulmonary artery is dilated. there is no pericardial effusion. . cxr: 1. improving pulmonary edema and bibasilar atelectasis. stable bilateral pleural effusions. 2. continued right upper lobe opacity of uncertain etiology. this could represent post-radiation change, superimposed infection, or possibly active tumor in this area. the finding was discussed with dr. , who indicates a history of prior upper lobectomy of uncertain laterality that is followed in an outside hospital. clinical correlation is necessary. . echo : normal lvef, severe diastolic dysfunction. . blood cultures: + for seratia marscens (sensitive to zosyn). bronch sputum gram stain: +gnr. brief hospital course: 67 yo f with history of copd, chf, chronic trach originally presented with increased respiratory distress, cyanosis, hypoxia. . hypotension/sepsis: pt has been intermittently hypotensive s/p aggressive diuresis over the course of her admissing to the micu. these episodes have typically resolved with ivf boluses. on she developed respiratory distress felt aspiration of liquids, and developed hypotension requiring pressor support (levo/vaso, changed to neo/vaso). in addition to her underlying intravascular depletion, a septic and cardiogenic etiology were considered. cardiac enzymes were found to be elevated, and nstemi was diagnosed. troponins peaked at 0.19, and trended downward. a repeat echo showed no change in lvef, and severe diastolic dysfunction. pt was not felt to be a candidate for angioplasty or beta blockers her hypotension, but was treated with aspirin. blood cultures from showed gnr (serratia marscens), and sputum gram stain also showed gnr. pt was begun on a course of zosyn () and levaquin (). the patient was persistently hypotesive even after resolution of sepsis. the patient was switched from prednisone (for copd) to dexamethasone in order to perform an accurate stim test. as above, pt was started on a dopamine drip for hypotension during diuresis. however, even after the lasix drip was discontinued, pt remained hypotensive and required dopamine. the decision was made to stim the patient but given that she was already on prednisone, she was switched to decadron and fludrocort and a stim was done 48 hrs later. this was positive and she received a total of 5 days of fludrocortisone and hydrocortisone. following cessation of her high dose steroids, she was started on a slow prednisone taper. this should be slowly tapered over the next 2 weeks, ending in . she was started on midodrine for bp support given her persistant low vascular tone and difficulty weaning off pressors. neosynephrine was successfully weaneded off the neosynephrine and tolerated boluses of lasix to keep her fluid status even to negative. respiratory failure: initial bronchoscopy on admission was concerning for peritracheal ulceration and granulation tissue with some tracheal obstruction and leakage of the the tracheal cuff. pt was unable to lie flat for airway ct, and was taken to the or on for rigid bronchoscopy revealing severe left mainstem bronchus and trachel malacia without ulceration. a y stent was placed with trach in the proximal end of the stent. pt was subsequently oxygenating and ventilating well on ac ventilatory support. trials of ps were intermittently succesful, although pt continued to experience episodes of respiratory distress ongoing tracheal secretions, and volume overload which required her to be placed on ac ventilation. in addition to albuterol, atrovent, and flovent, pt was started on a course of solumedrol () tapered to prednisone for copd exacerbation. on pt was found to be in respiratory distress with frothy pink sputum suctioned from the trachea. she was diagnosed with a serratia pneumonia and treated with unasyn and levaquin x 14 days. following resolution of her pneumonia, she was placed on pressure support and weaning trials were attempted daily. she is currently on pressure support of 10 and peep 10. during two trach collar traials she became tachypneic but abg's remained stable. please try to wean off ps further. the patient should follow-up in about 4 weeks as an outpatient at the for a bronchoscopy. . serratia sepsis / pseudomonas & acinetobacter pneumonia: the patients blood cultures from grew out serratia. sputum also grew serratia and acinetobacter. she was treated with unasyn/levofloxacin for a 14 day course. due to persistent hypotension, she was recultured, including a bronchscopy which grew out pseudomonas and acinetobacter sensitive to cefepime. she will complete a 14-day course of cefepime on . chf/nstemi: pt continued to appear severly volume overloaded on clinical exam, although she is intravascularly volume depleted as evidenced by low uop and drops in bp with attempts to diureses. repeated attempts to diurese have been initially successful (removing ~1l), but ultimately resulted in hypotension. cardiac enzymes were found to be elevated on and an nstemi was diagnosed. troponins peaked at 0.19, and trended downward. a repeat echo showed no change in lvef, and severe diastolic dysfunction. pt was not felt to be a candidate for angioplasty or beta blockers her hypotension, but was treated with aspirin. afib: pt had atrial fibrillation with increasing rate on levophed so she was transitioned to neosynephrine for bp support while septic. when stable, she could not tolerate bb or ccb for rate control so she was restarted on digoxin. she tolerated this well. dmii: controlled with insulin gtt initially, now controlled with sq insulin. anemia: originally felt to be tracheal secretions, and chronic disease. pt initially on epo, discontinued as anemia not likely related to epo deficiency. her hct remained stable and then slowly began to trend down. she was transfused prbc for a goal hct of >21. fen: pt had been eating prior to arrival while being ventilated with ac ventilation. she was seen by speech and swallow consult once transitioned to ps ventilation, and cleared for clear liquids after a video swallowing study. however, she subsequently developed respiratory distress and pna felt to aspiration, and was thus made npo by mouth. she has been receiving tf via ngt since . the family is opposed to the placement of a peg at the time of this summary. psych: towards the end of the hospital stay, pt started having delusions. it seemed to coincide with the initiation of high dose steroids. she was not started on any anti-psychotics as she was not a harm to herself or others. she was continued on her antidepressants. code: full medications on admission: kcl 20 meq lasix 40 ceftaz 2gm q8hr (day ) solumedrol 40mg q 12h (day ) iss reglan 5mg po tid protonix 40mg po qd paxil 20mg po qd epogren 20,000u q fri digoxin 0.125 qd asa 325 qd colace 100 qd senna 2 tabs florinef 0.1 mg qd lactulose 30 ml combivent mdi 6 puffs qid flovent 110 mcg 4 puffs albuterol nebs q2h prn morphine 2 mg q 4 prn tylenol lidocaine 2% gel to trach stoma prn ambien 5mg po qhs prn ativan 1 mg q4hrs prn allergies: phenergan discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: five (5) puff inhalation q4h (every 4 hours). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. paroxetine hcl 10 mg tablet sig: two (2) tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 10. cefepime 2 g piggyback sig: two (2) grams intravenous q8h (every 8 hours): last day . 11. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 12. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 13. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 14. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 15. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 16. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 17. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 18. atrovent 18 mcg/actuation aerosol sig: five (5) puffs inhalation every six (6) hours. 19. insulin nph human recomb 100 unit/ml suspension sig: eight (8) units units subcutaneous twice a day. 20. insulin lispro (human) 100 unit/ml solution sig: as directed units subcutaneous four times a day: per sliding scale. 21. prednisone 10 mg tablet sig: three (3) tablet po daily (daily): taper off 10mg every three days. 22. furosemide 40 mg tablet sig: one (1) tablet po tid (3 times a day): hold for map<55. 23. 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. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: broncho-tracheomalacia diastolic chf copd pneumonia secondary: diabetes type ii hx lung ca discharge condition: stable, oxygenating well on pressure support discharge instructions: to care providers: please pursue aggressive respiratory rehab. plan follow up with interventional pulmonology at (in weeks for a flexible bronchoscopy to ensure correct stent placement / lack of granulation tissue. . please continue to try and wean pressure support and peep with goal of trach mask. please try and aggressively decrease both ps and peep. . assess fluid status, measure daily weights, fluid intake and output and give lasix as needed to keep negative. her baseline bp is 90's/40's. adjust lasix dose as needed. . she needs to finish a 14 day course of antibiotics (last day of cefepime should be ) . please taper her po steroids slowly over the next 2 weeks. today is day 2 of 30mg prednisone. followup instructions: please follow-up with your regular physician . please follow up with interventional pulmonology at (in weeks for a flexible bronchoscopy. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances other bronchoscopy other intubation of respiratory tract closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus bronchoscopy through artificial stoma bronchoscopy through artificial stoma bronchoscopy through artificial stoma transfusion of packed cells replacement of tracheostomy tube infusion of vasopressor agent diagnoses: anemia of other chronic disease subendocardial infarction, initial episode of care pneumonia due to other gram-negative bacteria congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis atrial fibrillation personal history of malignant neoplasm of bronchus and lung obstructive chronic bronchitis with (acute) exacerbation acute and chronic respiratory failure pneumonitis due to inhalation of food or vomitus long-term (current) use of insulin septic shock hypovolemia delirium due to conditions classified elsewhere other tracheostomy complications septicemia due to serratia 

Answer: The patient is high likely exposed to