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: meperidine attending: chief complaint: septic shock major surgical or invasive procedure: bal history of present illness: 73yo f with history of metastatic breast cancer, atrial fibrillation on coumadin, ulcerative colitis and cardiomyopathy presents transferred from for impending sepsis. . patient was doing well at rehab and was scheduled to go to for a surgical gtube but had a sudden hct drop/acute renal failure/worsening pulmonary function/waxing mental status and was transferred to . in rehab, she was apparently weaned to trach mask with speaking valve with occasional simv. she then had increased ventilatory support, ct chest show large right pleural effusion. patient had pigtail placed on . pleural fluid labs are pending. 1l has been put out. renal team felt that her arf was due to hypotension on in the setting of low hct. she also has persistant hyperkalemia. . of note, patient was just recently admitted from with pontine abscess. infectious source was not identified and neurosurgery fet that biopsy was too dangerous. she was treated with multiple antibiotics but eventually responded to penicillin g for suspicion of listeria. she is left with a significant l-facial paresis, is able to move her tongue, but with difficulties and remains unable to clear her secretions. she was intubated and trached because of that. she was also treated for mrsa and stenotrophomonas pna with vancomycin and bactrim. she also has significant proximal muscle weakness b/c steroid use. hospital course c/b gi bleed from supratherapeutic inr. egd showed avm. she also had multiple hypotensive episode, likely from primary brainstem lesion in combination with sedation, blood loss and also after large volume thoracentesis. she also developed anemia and thrombocytopenia with neg hit and eventually stabilized. she also deveoped bilateral large pleural effusion which was tapped, cytology showed atypical cells, concerning for adenocarcinoma. however, she was discharged when this result is available and there has been no follow up. past medical history: -breast cancer, diagnosed in ; bilateral with metastases to lymph nodes, s/p lumpectomy, local radiation and 5fu/adriamycin -osteoarthritis -s/p r-knee and l-hip replacement () -atrial fibrillation -rheumatoid arthritis -h/o adriamycin-induced cardiomyopathy -ulcerative colitis, s/p ileostomy -restrictive lung disease (related to radiation and/or amiodarone) -dilated cardiomyopathy social history: the pt denied use of tobacco or illicit drugs. she admitted to occasional alcohol use. the pt lives alone, not married, no children, gets assistance from health aids. at baseline walks with a cane. family history: no history of stroke or other neurologic disease. physical exam: t96.7 bp120/65 p110 ac400x20 peep5 fio2 0.6 gen- intubated, sedated\ heent- pupils dilated(r>l), sluggish to light(r>l), mmm,obese neck, hard to assess jvd cv- irregular, no r/m/g resp-decreased breath sounds bilateral bases(r>l), mild wheeze, pleural bag draining yellowish fluid, no accessory muscle use, no paradoxical breathing pattern abdomen- soft, obese, no bowel sound, ileostomy bag contains yeallowish watery stool neuro- opens eyes spontaneously, does not obey commands, equivocal plantar reflexes extremities- 3+ pitting edema, doplerrable distal pulses pertinent results: 11:43pm glucose-128* urea n-110* creat-1.4* sodium-137 potassium-3.6 chloride-95* total co2-33* anion gap-13 11:43pm alt(sgpt)-16 ast(sgot)-30 ld(ldh)-222 ck(cpk)-50 alk phos-297* amylase-283* tot bili-0.3 dir bili-0.2 indir bil-0.1 11:43pm lipase-138* 11:43pm ck-mb-3 ctropnt-0.14* 11:43pm albumin-2.3* calcium-8.2* phosphate-5.6*# magnesium-2.6 iron-24* 11:43pm caltibc-257* haptoglob-192 ferritin-617* trf-198* 11:43pm tsh-8.0* 11:43pm cortisol-18.4 11:43pm digoxin-less than 11:43pm wbc-14.1*# rbc-2.91* hgb-9.4* hct-30.1* mcv-103* mch-32.4* mchc-31.3 rdw-17.5* 11:43pm neuts-91.8* bands-0 lymphs-5.3* monos-2.5 eos-0.3 basos-0.1 11:43pm hypochrom-2+ anisocyt-2+ poikilocy-occasional macrocyt-2+ microcyt-normal polychrom-normal ovalocyt-occasional target-normal burr-occasional teardrop-occasional 11:43pm plt smr-normal plt count-288# 11:43pm pt-13.1 ptt-30.6 inr(pt)-1.1 11:43pm ret aut-2.4 . echo: impression:right ventricular cavity enlargement with pulmonary artery systolic hypertension. moderate-severe tricuspid regurgitation. preserved left ventriculary systolic function. mild-moderate mitral regurgitation. compared with the prior study (images reviewed) of , the severity of mitral regurgitation is now reduced. . ct chest: impression: 1. limited study due to artifact from the arm and left hip. 2. markedly increased subcutaneous edema in chest, abdomen, and pelvis. 3. status post thoracentesis with pigtail catheter terminating in the azygoesophageal recess. 4. increased ascites, measuring hounsfield units. 5. gallstones, without gallbladder distention. 6. status post tracheostomy, with slight overinflation of the balloon at the level of thyroid gland. 7. cardiomegaly with enlargement of right atrium. 8. bilateral pleural effusion. 9. increased bilateral patchy opacities with consolidation in right lower lobe, probably representing combination of edema, atelectasis, and possibly multifocal pneumonia. 10. status post left hip replacement. . ct abdomen: impression: 1. no evidence of retroperitoneal hematoma. 2. unchanged bilateral pleural effusions, left greater than right. improvement in consolidation seen at the right lung base, but with bibasilar atelectatic changes. 3. cholelithiasis without cholecystitis. 4. slight decrease in the amount of ascites seen in the abdomen. slight decrease in overall anasarca compared to the prior study. . bal: negative for malignant cells. . ct head: impression: 1. exam limited by motion. no evidence of acute intra- or extra-axial hemorrhage. 2. partial opacification of the sphenoid sinus and total opacification of the mastoid air cells which was also demonstrated on the ct scan of . ,: radiology detail - ccc record # final report history: 73-year-old woman status post complicated percutaneous g-tube placement. assess for positioning of the tube. technique: multidetector axial images of the abdomen and pelvis were obtained with contrast. 15 cc of gastrografin was subsequently infused through the gastrostomy tube and immediate scan of the gastrostomy site was performed followed by delayed imaging of the abdomen and pelvis. ct abdomen: there is a moderate-to-large left pleural effusion and small right pleural effusion with associated basilar atelectasis. the liver appears increased in attenuation on this non-contrast study. within the limits of this non-contrast study, the pancreas, spleen, adrenal glands, and kidneys are stable. the gastrostomy tube appears outside of the stomach lumen and is positioned posterior to the greater curvature of the stomach. injection of contrast reveals pooling of contrast within the mesentery and apparently extraluminal. on the delayed scan, approximately 10 minutes after injection, the contrast remains in unchanged position. no contrast is seen within the bowel. there is a large amount of intraperitoneal free air. free fluid is also seen tracking along the left pericolic gutter. large gallstones are again identified. ct pelvis: small bowel loops are not dilated. ileostomy is again noted. the bladder and rectum are stable. no pelvic free fluid is identified. there is no pelvic or inguinal lymphadenopathy. bone windows: there are no suspicious lytic or sclerotic osseous lesions. impression: 1. the percutaneous gastrostomy tube appears extraluminal and is located posterior to the stomach. there is a large amount of free air and small amount of free fluid along the left pericolic gutter. 2. moderate-to-large left pleural effusion and small right pleural effusion. the study and the report were reviewed by the staff radiologist. dr. tham ,: radiology detail - ccc record # final report history: 73-year-old woman status post complicated percutaneous g-tube placement. assess for positioning of the tube. technique: multidetector axial images of the abdomen and pelvis were obtained with contrast. 15 cc of gastrografin was subsequently infused through the gastrostomy tube and immediate scan of the gastrostomy site was performed followed by delayed imaging of the abdomen and pelvis. ct abdomen: there is a moderate-to-large left pleural effusion and small right pleural effusion with associated basilar atelectasis. the liver appears increased in attenuation on this non-contrast study. within the limits of this non-contrast study, the pancreas, spleen, adrenal glands, and kidneys are stable. the gastrostomy tube appears outside of the stomach lumen and is positioned posterior to the greater curvature of the stomach. injection of contrast reveals pooling of contrast within the mesentery and apparently extraluminal. on the delayed scan, approximately 10 minutes after injection, the contrast remains in unchanged position. no contrast is seen within the bowel. there is a large amount of intraperitoneal free air. free fluid is also seen tracking along the left pericolic gutter. large gallstones are again identified. ct pelvis: small bowel loops are not dilated. ileostomy is again noted. the bladder and rectum are stable. no pelvic free fluid is identified. there is no pelvic or inguinal lymphadenopathy. bone windows: there are no suspicious lytic or sclerotic osseous lesions. impression: 1. the percutaneous gastrostomy tube appears extraluminal and is located posterior to the stomach. there is a large amount of free air and small amount of free fluid along the left pericolic gutter. 2. moderate-to-large left pleural effusion and small right pleural effusion. the study and the report were reviewed by the staff radiologist. dr. tham ,: radiology detail - ccc record # preliminary report indication: history of breast cancer, pneumonia, with multiple medical problems, acute renal failure, dic, sepsis. evaluate for interval change. single portable chest radiograph with comparison to examination from one day ago shows increase in the size of the left-sided loculated effusion. right-sided effusion is not significantly changed. again, there are diffuse pulmonary opacities, more on the left than the right, largely due to effusion with combination of atelectasis. there is persistence of retrocardiac opacity. the cardiac silhouette is probably within normal limits in size. lines and tubes are unchanged in position, with tracheostomy approximately 3 cm above the carina, right ij in the upper svc, and left-sided picc in the mid svc. no pneumothorax. impression: slight increase in left-sided loculated effusion, otherwise unchanged. ,: microbiology detail - ccc record # 4:24 pm swab source: g tube effluent. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 4+ (>10 per 1000x field): gram positive cocci in pairs. 2+ (1-5 per 1000x field): gram positive cocci in short chains. 4+ (>10 per 1000x field): gram negative rod(s). brief hospital course: hospital course: 73yo f with history of metastatic breast cancer, atrial fibrillation on coumadin and amiodarone, gib from avm, ulcerative colitis with ileostomy, adriamycin-induced cardiomyopathy, transferred from rehab for hypotension: . ## septic shock from acinetobacter/stenotrophomonas/pseudomonas pneumonia: last admission patient was admitted and discharged from icu. baseline blood pressure per omr records were above 100s. during last admission, she has multiple hypotensive episode in the setting of sedation, blood loss and large volume thoracentesis. during this admission, patient's bp ranged from 80-130, with sbp often running around 80 at night. pt had had r thoracentesis and pigtail cath placed on the day before admission. she was treated with aggressive ivf for the first several days of admission, with response in her bp. she was guaiac negative x 3. ct head showed stable sinus findings and stable pontine abscess. ct abdomen showed small ascites, but no retroperitoneal bleed. pleural fluid was clear, yellow, nonbloody. pt had pancreatitis with elevated amylase/lipase, and was treated with ivf, npo, analgesia, but hct was stable. map was maintained >65, cvp>10. pt was on levophed from admission until , and then after sepsis cleared, pt was diuresed with stability in bp. . for possible meningitis, pt was started on empiric vancomycin and ceftriaxone. lp was found to be negative. bal showed acinetobacter, stenotrophomonas, and pseudomonas. throughout admission, patient was placed on vanco, ceftriaxone, bactrim, levofloxacin, meropenem for the pneumonia. meropenem was the last antibiotic, that was stopped on . patient remained stable off antibiotics. she had another episode of uti with pseudomonas and was treated for a 7 day cousre. . pt was placed on stress dose steroids on , since she takes prednisone 10 qd for uc. she was ruled out for an mi, and ruled out for a pe (pt has metastatic breast ca). . ## respiratory failure: patient was on trach and vent since admission. pt underwent effort to wean from vent in , but vd/vt was found to be 70-80% on 4 measurements. she was placed on ac and simv, with occasional episodes of ps. decreased fio2, peep, vd/vt of 70%: portends very difficult (if at all possible) wean. she will likely need chronic vent facility. on there were difficulties with trach seal. ent was consulted who changed her from a bovano to portex 7 trach (size of trach the same). she was also evaluated by ip for a tracheal stent and they recommended that if she has problems with trach again, she will likely need a longer (length of trach) rather than a stent. she did not have any further problems with the trach. . ## acute renal faiure: patient was admitted in acute renal failure, which was found to be prerenal in the setting of hypotension. her arf resolved after 2 weeks, and her creatinine returned to her baseline of 1.2. creatinine was monitored during the stay as she was on lasix drip, see below. . ## 4+ anasarca: patient was given aggressive ivf on admission, with resultant 5+ pitting edema. after stabilization of bp and treatment of infection and weaning off of levophed, patient was diuresed gently with lasix gtt. patient's creatinine was stable, and remained around baseline. the edema however did not resolve with lasix gtt. starting her creatinine started to increase and lasix gtt was held. she will need to be diuresised further as her bp and renal insufficiency tolerates it. . ## hct decrease: patient required blood transfusion every week prior to admission. guaiac was negative x 3, hemolysis labs were negative, pt was taking fe and folic acid. iron studies showed anemia of chronic disease. she had one episode of hct <20, hemolysis labs were negative, anca negative and there was no clear source. she was later found to have a l chest wall hematoma, her inr was supratherapeutic at the time and was held thereafter. surgery was consulted who suggested monitoring the hematoma as there would be a chance of wound infeciton. there were no further episodes like this. given her anemia of chronic disease she should be started on epogen after discharge from hospital. . ## atrial fibrillation: metoprolol and diltiazem did not work well for patient's afib, because her bp would decrease below 80. she was started on amiodarone with reasonable rate control in the 100s. anxiety (ativan) and pain (dilaudid, morphine, percocet) medications also served to decrease patient's hr. pt ordinarily took coumadin as an outpatient, but coumadin was held during admission, for hematocrit drop as above. she had several episodes of tachycardia and cardiology was consulted who recommended digoxin. her hr was better controlled thereafter. . ## diabetes mellitus 2: patient was maintained on insulin gtt, and then insulin sliding scale starting until discharge. . ## r chronic endophthalmitis/r retinal detachment: ophthalmology agreed that pt would not undergo surgery to correct her retinal detachment, and would not require further antibiotics intravitreally. ultrasound x 2 showed choroidal detachment as . at , vitreous culture showed p. acnes, was injected intravitreally with vanc/ceftazidime. patient was maintained on 4 eyedrops and erythromycin ointment as outpatient. contact at is dr. (retina). . ## metastatic breast ca: patient follows with dr. at . she was placed on letrozole starting on . it is believed that her pleural effusions are associated with her breast ca. cytology from r pleural fluid had shown cells suspicious for malignancy, but pleural fluid sent at did not show malignant cells. . ## adriamycin-induced cardiomyopathy: echo during last admission show ef60% with 3+ mr and 4+ tr. echo during this admission showed an improved mr to 2+. . ## ulcerative colitis with ileostomy: patient was admitted on prednisone 10 qd. her dose was decreased to 5 qd, and was continued to be tapered down. gi was consulted, who confirmed that pt does not require prednisone for her uc since her colon has been resected. . ## gallstone: patient had elevated alkaline phosphatase, amylase, lipase, with gallstones visualized in gb. patient was treated by npo, ivf, and dilaudid, morphine, percocet for pain control. lfts improved slowly over time. . ## uti: episode of pseudomonas uti, treated with ceftaz for 7 days, last day ~. . ## fen: patient was admitted with an ngt, and had an ogt placed. she was kept on nepro at 35 ml/hr initially. surgery was consulted several times for peg placement, however given her anasarca and ascities they believed that her risk for peg complications would be high. this was a limiting factor for her prior to discharge as she did not have any souce of nutrition other than ngt and nursing home wanted a post pyloric ng. gi was consulted who were successful in placing post pyloric ng tube, however a few hours later pt pulled the ng tube. ir was consulted and placed a peg tube under floro guidance. she will be started on tfs via peg> . ## code: full . ## communication: hcp (brother) ) on / percutaneos g tube was attempted and it was felt not to be optimal procedure for this reason it was further studied and found to have a leak for this reason several days it was observed by the ir and medical icu team, following that the tube and then manipulated and interrogated and found to have a leak again on , on a ct scan was ordered and the results were called to the team that the g-tube was freely out in the peritoneum. at this juncture surgery was called. after extensive discussion that the patient was in grave state and needed to have emergency surgery for a likely gastric perforation :this was repaired on the evening on into the early morning of . and was transferred to the icu thoughout this post operative course she continued to have a fluid requirement her creatinine rose steadily and she eventually became anuric in atn, throuout this period she developed a pressor requirement that steadily increased and her pulmonary status worsened. on a dialysis line was placed for pending dialysis. after placement of the dialysis line she continued to have spetic appearing physiology but had an additional pressor and blood requirement having a crit drop of several units. this cycle of sepsis and increased blood requirement continued and again extensive discussion was taken with the family regarding the goals of care. she continued to progress and have failure of all organ systems having a continued blood product requirement from potential retroperitoneal bleed related to line placement, dic related to sepsis, and vent dependent pulmonary failure, as well as acute renal failure all the while on maximum pressor suport. again extensive discussion was undertaken with her kind and responsive family who felt as if they were being consistent with her wishes to continue until it was reached that the most important goal of therapy could no longer bring meaningful survival. after this discussion was undertaken the patient was made comfort measures only and the ionotropic support was weened and the patient expired shortly after with her family present at the bedside medications on admission: prevacid 30g per ng tube caco3 500mg per ng erythromycin xopenex atrovent folic acid lopressor 75mg q8h digoxin 0.125 riss coumadin prednisone 10mg qd zofran prn percocet prn renagel 1600mg 3x/day ertapenem 1g q12 through coumadin discharge medications: none discharge disposition: extended care discharge diagnosis: sepsis, metastatic breast cancer, blood loss anemia, ventdependent respiratory failure, pontine abscess, acute renal failure, cardiomyopathy, shock liver, gastric perforation, failure to thrive , malnutrition, tpn dependence, htn, ocular infection, discharge condition: none discharge instructions: none followup instructions: none 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 enteral infusion of concentrated nutritional substances venous catheterization for renal dialysis percutaneous [endoscopic] gastrostomy [peg] closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus bronchoscopy through artificial stoma replacement of tracheostomy tube replacement of gastrostomy tube suture of laceration of stomach injection or infusion of oxazolidinone class of antibiotics sinogram of abdominal wall diagnoses: other primary cardiomyopathies pneumonia due to other gram-negative bacteria acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension long-term (current) use of steroids acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver unspecified protein-calorie malnutrition severe sepsis atrial fibrillation secondary malignant neoplasm of pleura personal history of malignant neoplasm of breast accidental puncture or laceration during a procedure, not elsewhere classified defibrination syndrome pneumonia due to pseudomonas septic shock long-term (current) use of anticoagulants mechanical complication due to other implant and internal device, not elsewhere classified septicemia due to anaerobes acute pancreatitis intracranial abscess chronic respiratory failure attention to tracheostomy septicemia due to pseudomonas other forms of retinal detachment chronic endophthalmitis 

Answer: The patient is high likely exposed to