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: motrin / latex attending: chief complaint: tracheostomy evaluation, concern for altered mental status major surgical or invasive procedure: 1. flexible bronchoscopy. 2. tracheostomy tube change history of present illness: this is a 62 year old female, with a past medical history of atrial fibrillation, memory loss s/p hypoglycemic coma with anoxic brain injury, chronic low back pain, subarachnoid hemorrhage, chronic hypercarbic respiratory failure with tracheostomy in place, who now presents for removal of trach, and concern for altered mental status. this patient has a complicated past medical history in which she was admitted for subarachnoid hemorrhage (), discharged and then subsequently re-admitted for hyperbaric respiratory failure requiring intubation (). her hypercarbic respiratory failure is thought to be due to multiple causes, including central and obstructive apnea, a chronic paralyzed right hemidiaphragm, and obesity hypoventilation. on her third admission (), again for acute hypercarbic respiratory failure requiring intubation, she was found to have a tracheal tear seen on chest cta, and confirmed on bronchoscopy. tracheostomy was performed to bypass the area of the tear, as the patient was at high risk for repeated intubation and the risk of causing perforation would be greater in setting of re-intubation. the initial plan was to re-evaluate the tracheostomy in 8 weeks after the tear healed. however, in the interim, patient decided with her pcp to leave the trach in place as treatment for the patient's presumed osa. trach removal was further delayed by two hospitalizations at for pneumonia. she now presents for removal of trach. her husband is also concerned for the patient's worsening mental status, with confabulation and loss of memory. she has reportedly been confused, not recognizing her husband and other family members. she has baseline dementia as a result of anoxic brain injury and hypoglycemic coma, but he reports that over this has worsened over the last few weeks to months. the patient denied these symptoms and further denied any fever, chills, headache, vertigo or focal weakness. past medical history: left temporal intraparenchymal hemorrhage copd - no prior h/o tobacco use, + secondhand exposure afib - was on coumadin for last few years,anti-coagulation was discontinued after her ich tia - had prior episodes of flashes of light going across her visual field, was placed on plavix. dementia - secondary to diabetic coma with anoxic brain injury chronic low back pain anemia gerd chronic hypercapnic respiratory failure with history of traumatic tracheal tear, s/p tracheostomy placement on - apparently multifactorial in etiology, including central and obstructive apnea, chronically paralyzed r hemidiaphragm, and obesity hypoventilation. seen by sleep who recomended her bipap settings. social history: lives with husband until recent admission, used to work as the press secretary to a state senator in the state house. no /etoh or illicits. husband was mechanically ventillating patient at night at home. family history: nc physical exam: admission vitals: t:98.1 bp:175/51 p:86 rr 19 o2: 95%3l discharge vitals: t 96.2 bp: 148/50 p:60 rr: 21 02: 05% on 2l general: alert, oriented x3, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation, respirations unlabored, no accessory muscle use cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: neuro: a&ox3, appropriate, cns ii-xii grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, dtrs 2+ and symmetric spine: c/t/l-spine without ttp . pertinent results: 03:26pm blood type-art po2-78* pco2-58* ph-7.43 caltco2-40* base xs-11 02:42am blood type-art po2-82* pco2-63* ph-7.40 caltco2-40* base xs-10 intubat-not intuba 05:11am blood wbc-12.6* rbc-4.08* hgb-10.4* hct-33.5* mcv-82 mch-25.6* mchc-31.2 rdw-16.7* plt ct-320 11:15am blood wbc-10.0# rbc-4.36# hgb-11.2*# hct-35.9*# mcv-82# mch-25.7*# mchc-31.2 rdw-17.1* plt ct-359 04:55am blood pt-12.6 ptt-23.5 inr(pt)-1.1 05:11am blood glucose-261* urean-13 creat-0.6 na-136 k-4.0 cl-100 hco3-25 angap-15 03:24am blood glucose-142* urean-11 creat-0.6 na-142 k-3.8 cl-103 hco3-27 angap-16 03:24am blood alt-6 ast-13 ck(cpk)-19* alkphos-94 totbili-0.3 04:55am blood calcium-9.2 phos-4.0 mg-1.9 03:24am blood vitb12-649 12:10pm blood lactate-1.1 cxr : low lung volumes limit evaluation of the lung parenchyma. mild nodular interstitial thickening especially within the left lower lobe may represent atelectasis versus early pneumonia. clinical correlation is recommended. ct head : the ventricles are moderately enlarged given the lack of significant atrophy, particularly the third ventricle. overall, the size of the ventricles is not significantly changed when viewed over serial images dating back to the patient's presentation in of this year. there is continued evolution of the left temporal lobe hematoma, with vague lucency, though no evidence to suggest interval bleeding. no persistent intraventricular blood products are seen. there is hyperostosis frontalis. there are no findings of acute infarct by ct. the visualized paranasal sinuses and mastoid air cells are clear. cxr : right low lung volume with elevation of the right hemidiaphragm is stable. new airspace opacity in the right lung suggests early pneumonia in the right clinical setting. left lung is grossly clear. ct abd/pelvis : acute compression fracture at t12 without other evidence to explain abdominal pain. brief hospital course: this is a 62 year old female, with a past medical history of atrial fibrillation, memory loss s/p hypoglycemic coma with anoxic brain injury, chronic low back pain, subarachnoid hemorrhage, chronic hypercarbic respiratory failure with tracheostomy in place, who presented to the emergency department for removal of trach, and concern for altered mental status. the patient was initially admitted to the icu in order to receive mechanical ventilation at night. in the micu, she was weaned off of the vent, and when transfered to floor, was able to cap her trach during the day and remove the cap at night--no other respiratory intervention was thought to be necessary. additionally, while in th icu, the patient complained of back and ruq pain; abdominal ct to evaluate these complaints did not show any acute intraabdominal pathology, but did show an acute thoracic compression fracture. there was some concern that the patient was developing pneumona, as she had increasing white count, increased secretions over a few days prior to transfer to the floor, as well as a chest xray with new infiltrate in the right lower lung. . #1. chronic hypercapnic respiratory failure: apparently the pt's respiratory failure is the result of etiologies, including central and obstructive sleep apnea, a chronic paralyzed r hemidiaphragm, and obesity hypoventilation. the patient was evaluated in by sleep pulmonology and recommendations for outpatient sleep study and empiric bipap were made. although the patient did well with nocturnal ventilator/bipap weaning in the micu, on the floor, she had rising bicarb (from 25 to 35 over 4 days) and sleep pulmonology was consulted to provide recommendations on whether the patient should be on any kind of positive pressure ventilation at night, and if so, at what settings. abgs were checked during the day and while the patient was asleep on bipap to assess for hypercarbia on those settings--pco2 was stable from 58 (day) to 63 (night) and the patient's o2sat was 94% overnight. per their recommendations, the patient was re-started on bipap 10/5 with 2l 02 with full face mask and capped trach. the patient should also sleep at 35 degrees at all times to optimize pulmonary mechanics. the patient is scheduled for out-patient sleep study and follow up with dr. . during her hospitalization, her respiratory status remained stable with rr ranging 20-24, o2sat >93% on 2l of 02. at night, she was >89% on 4-5l. . #2. tracheal tear s/p tracheostomy: as noted in hpi, pt's trach was supposed to be re-evaluated in weeks but this never happened due for multiple reasons as noted above. the patient was evaluated by ip while in the micu, and had her tracheostomy downsized from #7 to #6 . the initial plan was to cap the trach for 72 hrs, and, if tolerated, then change it to a tracheal cannula to preserve the stoma while she got tested for osa. however, the patient was unable to tolerate capping of the trach during the night. when transfered to the floor, she was capping the trach during the day and leaving it uncapped at night. the patient needs to follow up with ip as well as sleep pulmonlogy as an out-patient. . #3. pneumonia: on transfer to the floor, there was concern for developing pneumonia, given that the patient had increasing wbcs, increasing respiratory secretions and new right lower lobe infiltrate on chest xray. id consult was obtained to provide antibiotic recommendation and the patient was started on meropenem iv for 7 days, per susceptibilties from osh cultures. sputum cultures from and subsequently grew pseudomonas aeruginosa and serratia marcescens, two of the same organisms seen in the osh cultures. her last day of antibiotics (meropenem) is . . #4. altered mental status: while admitted, the patient's mentation appeared completely appropriate during the day. at night, she did seem to experience some degree of sundowning as she occasionally became confused about what hospital she was at and how long she had been admitted; she would also confabulate stories about things she had supposedly done with her family on preceding days. she was very re-directable and could be reoriented easily. during the day, she was alert and oriented x 3. work up included a head ct negative for any new large stroke or hemorrhage, b12 normal, and rpr negative. her mental status was stable during her admission on the floor and her husband reported that she was at baseline. . #5. acute anterior compression fracture at t12: the patient's compression fracture was discovered incidentally on a ct abdomen obtained to evaluate the patient's complaint of abdominal pain. she was then seen by orthopedics, who recommended tlso brace and follow up in 2 weeks with dr. . pt evaluated the patient and recommended rehab after discharge. given the concern for osteoporosis in the setting of incidental compression fracture, the patient was started on vitamin d and calcium supplementation. the patient is weight-bearing with tlso brace. without brace, hob cannot be >40 degrees. she was given percocet and fentanyl patch for pain control. . #6. atrial fibrillation: on her home regimen of acebutolol, the patient became bradycardic. it was decreased to 100mg with good rate control. anti-coagulation with coumadin 5mg daily was re-started as an in-patient, with neurosurgery's approval. she will need her inr checked and her coumadin dose adjusted as needed. . #7. left temporal intraparenchymal hemorrhage: the patient's head ct was consistent with evolution of prior bleed; no extension or new hemorrhage was seen. the patient will need follow up with neurosurgery in 3 months with repeat head ct. additionally, the patient no longer needs to take keppra for seizure prophylaxis, per neurosurgery. . #8. diabetes: while admitted, the patient's home oral glycemic agents were held and she was maintained on a regular insulin sliding scale. she required addition of pm lantus dose (16 units) for improved glucose control. she was discharged on her oral hypogylcemic regimen. . #9. hypertension: blood pressure control was achieved with acebutolol 100 and enalapril 20mg twice daily. . # ruq abdominal pain: while in the micu, the patient had normal lfts and an abdominal ct that was negative for acute intra-abdominal process. she had negative c. diff toxin assay x 1. her pain improved on a bowel regimen and pain control for her thoracic compression fracture. . medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 2-4 puffs inhalation q4h (every 4 hours) as needed. 2. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 4. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed. 5. omeprazole 20 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po daily (daily). 6. simvastatin 40 mg tablet : two (2) tablet po daily (daily). 7. levetiracetam 500 mg tablet : one (1) tablet po bid (2 times a day). 8. acebutolol 200 mg capsule : one (1) capsule po bid (2 times a day). 9. rosiglitazone 2 mg tablet : two (2) tablet po daily (daily). 10. glipizide 5 mg tablet : 0.5 tablet po bid (2 times a day). 11. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed. 12. olanzapine 5 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po (once a day (at bedtime)) as needed for agitation. 13. brimonidine 0.15 % drops : one (1) drop ophthalmic q8h (every 8 hours): both eyes. 14. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime): both eyes. 15. humalog/regular insulin sliding scale (not clear per husband) per protocol q 16. januvia 100 mg tablet : one (1) tablet po once a day. (not clear per husband). 17. enalapril maleate 20 mg po daily discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 2-4 puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 3. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed for rash. 4. omeprazole 20 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po daily (daily). 5. simvastatin 40 mg tablet : two (2) tablet po daily (daily). 6. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain: do not take more than 4g of tylenol in 24 hours. 7. brimonidine 0.15 % drops : one (1) drop ophthalmic q8h (every 8 hours). 8. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime). 9. enalapril maleate 10 mg tablet : two (2) tablet po twice a day. disp:*90 tablet(s)* refills:*0* 10. oxycodone-acetaminophen 5-325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain: do not drive while taking this medication. do not take more than 4g of tylenol daily. do not take if you become very sleepy or have difficulty breathing. disp:*30 tablet(s)* refills:*0* 11. warfarin 5 mg tablet : one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 12. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily) as needed for pain. disp:*15 adhesive patch, medicated(s)* refills:*0* 13. guaifenesin 100 mg/5 ml syrup : 5-10 mls po q6h (every 6 hours) as needed for cough. 14. trazodone 50 mg tablet : one (1) tablet po hs (at bedtime) as needed for insomnia. 15. meropenem 500 mg recon soln : one (1) recon soln intravenous q6h (every 6 hours) for 4 days: day #1 . last day . disp:*qs recon soln(s)* refills:*0* 16. ipratropium bromide 17 mcg/actuation aerosol : 2-6 puffs inhalation qid (4 times a day). 17. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q6h (every 6 hours) as needed for wheezing. 18. acebutolol 200 mg capsule : one (1) capsule po twice a day. 19. zyprexa zydis 5 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po at bedtime as needed for agitation. 20. calcium 500 + d 500 mg(1,250mg) -400 unit tablet, chewable : one (1) tablet, chewable po twice a day. disp:*60 tablet, chewable(s)* refills:*0* 21. oxygen 3-6 l of o2 titrated into bipap for nocturnal use. 22. bipap bipap machine at 10/5 cm of h20 with heated humidification. 23. acebutolol 200 mg capsule : 100mg capsules po twice a day. 24. rosiglitazone 4 mg tablet : one (1) tablet po once a day. 25. glipizide 5 mg tablet : 0.5 tablet po twice a day. 26. januvia 100 mg tablet : one (1) tablet po once a day. 27. fentanyl 12 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 28. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day) as needed for calcium supplementation. 29. heparin, porcine (pf) 10 unit/ml syringe : one (1) ml intravenous prn (as needed) as needed for line flush. discharge disposition: extended care facility: discharge diagnosis: primary diagnoses: 1. chronic hypercapnic respiratory failure with history of traumatic tracheal tear, s/p tracheostomy 2. hospital-acquired pseudomonas pneumonia 3. acute anterior compression fracture at t12 4. dementia secondary diagnoses: 1. left temporal intraparenchymal hemorrhage 2. atrial fibrillation 3. diabetes mellitus 4. copd 5. hypertension discharge condition: stable. discharge instructions: you were admitted for revision of your tracheostomy. you had your tracheostomy downsized from a 7mm to a 6mm tube by interventional pulmonology. there was concern that you were developing a pneumonia, as you had increasing secretions, increaseing white count, and possibly a new infiltrate on chest x-ray. you were started on an iv antibiotic, called meropenam, for this and you will need 7 days of antibiotic therapy. you had complaints of abdominal pain while admitted, and had a ct scan of your abdomen--it did not show any intraabdominal pathology but did show a compression fracture of your thoracic spine (t12). additionally, we discussed your case with neurosurgery, who made the recommendations that your keppra (levetiracetam) 500mg twice daily can be stopped and that we could re-start your coumadin (aka warfarin--a blood thinner, which you take because your atrial fibrillation increases your risk of clotting). medication changes: we stopped your keppra 500mg twice daily. we started coumadin (warfarin) 5g daily for atrial fibrillation. we changed your enalapril from 20mg daily to 20mg twice a day to improve your blood pressure control. we decreased your acebutolol dose from 200mg twice daily to 100mg twice daily. we started calcium and vitamin d supplementation to help strengthen your bones. we started several medications to help control your pain from the compression fracture: 1. you may take tylenol 325mg (1 or 2 tabs) every 6 hours as needed for pain. 2. you may take 1 percocet (hydrocodone + tylenol). every 6 hours as needed for pain. 3. you may place a lidocaine patch on your back for 12 hours daily to help with pain. 4. you may place a fentanyl patch (12.5mcg) every 72 hours to help with your pain. be careful not to drive while using the percocet and fentanyl patch. be careful not to take more than 4g of tylenol in a day. 5. meropenem was started for pneumonia and will be continued until . please speak with your doctor at rehab if you have any decrease in your mental status or somnolence (severe sleepiness), confusion, any difficulty breathing, any increased cough or respiratory secretions, chest pain, fever, chills, nausea, vomiting, worsening or changed abdominal pain, diarrhea, leg weakness, incontinence of bowel, or any other new and concerning symptom followup instructions: you have had referrals made by your regular doctor and have the following appointments: 1. sleep apnea follow-up (friday) 9 am 8, neurology suite dr. and dr. 2. you can call interventional pulmonology at ( to make an appointment to evaluate your tracheostomy. 3. you have an appointment scheduled with dr. (with orthopedics) on at 4pm. you have an appointment on 1130am with your regular doctor dr. , ph . location: address: 26 city mall, , md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours bronchoscopy through artificial stoma replacement of tracheostomy tube diagnoses: anemia of other chronic disease obstructive sleep apnea (adult)(pediatric) unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled chronic airway obstruction, not elsewhere classified atrial fibrillation other persistent mental disorders due to conditions classified elsewhere other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonia due to pseudomonas anoxic brain damage osteoporosis, unspecified other late effects of cerebrovascular disease obesity, unspecified delirium due to conditions classified elsewhere disorders of diaphragm chronic respiratory failure pathologic fracture of vertebrae attention to tracheostomy memory loss late effect of complications of surgical and medical care central sleep apnea in conditions classified elsewhere 

Answer: The patient is high likely exposed to