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: altered mental status, cough, diarrhea major surgical or invasive procedure: tracheostomy left av fistula repair right femoral tunnelled dialysis line catheter placement history of present illness: mr. is a 74m with an extensive past medical history, and multiple recent hospitalizations for altered mental status and group b strep sepsis, who was recently discharged on after two serial hospitalizations for this. he was doing well after discharge from the hospital on until wednesday (two days pta), when he developed pain with his tube feeds, nausea, and vomiting. his daughter reports that he would experience abdominal pain soon after the onset of his tube feeds, which would resolve soon after she shut them off. he vomited on wednesday. later that day at dialysis, he required supplemental oxygen, which is new for him. on thursday, he developed a productive cough, and was unable to clear his secreations. today, he developed worsening shortness of breath. . review of systems is otherwise notable for bleedig (~1pint) from his fistula, increased somnolence. she denies any fevers, chills, sweats, skin rashes, diarrhea, or le edema. . in the emergency department presenting vital signs were t=96.6, bp=122/54, hr=72, o2sat=90%ra. on exam, he was initially non-responsive to sternal rub, then became verbal during an attempt at an abg. laboratory data is notable for mild hypernatremia (147), elevated bicarb to 42 ( in the low 30s), hct drop to 26.7 ( ~30), and a poistive ua. a cxr was abnormal but unchanged with his known large right loculated pleural effusion. a left sided ij was placed as the patient has limited access, blood cultures were drawn, and he recieved ceftriaxone and vancomycin for possible urine source vs. aspiration pna. past medical history: -cabg after mi (at : lima to lad, svg to om1, svg to pda) -post-operative r.mca cva ~1wk after cabg-pt with resultant hemiplegia, aphasia, dsyphagia. -post-op large rue dvt -status-post respiratory failure from cva, now weaned of vent. -hypertension -peripheral vascular disease, status-post left popliteal-dorsalis pedis bypass with saphenous vein graft -s/p sepsis at in -diabetes mellitus, type ii. diagnosed 40 years ago, complicated by nephropathy, neuropathy (sensory and autonomic leading to urinary retention) and retinopathy (s/p bilat vitrectomies, l eye blindness). -esrd initially secondary to diabetic nephropathy starting dialysis in . - s/p chronic allograft insufficiency s/p r cadaveric kidney transplant, complicated by postinfectious gn (negative , anca, low complemt), signs of chronic rejection (sclerotic glomeruli, interstitial fibrosis 3/). -chronic anemia -neurogenic bladder -bph status-post turp . -chronic osteomyelitis of c-spine and bilateral feet, s/p bilateral transmetatarsal amputations (r foot , l foot ). -hsv stomatitis/genital -recurrent uti -blindness in r eye following cva (both eyes ) -adrenal insufficiently diagnosed this year. -pacer/icd placed for chb or mobitz ii (records conflicting) social history: originally from , emigrated in . retired civil engineer. lives at home with family, who provide chronic care. at , is , tube dependent, and does verbalize with his family. prior etoh and tobacco, not currently. family history: mother and brother with dm type 2. he also has a cousin with asthma and brother with lung cancer. physical exam: t=97.2 rectally... bp=125/60... hr=67... rr=20... o2=100% 2lnc general: somnolent, does not respond to voice, does respond to sternal rub, but does not answer questions. cold to touch. : right pupil reactive to light. will not open his mouth for exam. cardiac: bradycardic, with frequent pvcs. no murmurs. no jvd. lungs: moving air anteriorly. decreased bs at right base. abdomen: tube c/d/i, nabs, no wincing or guarding with deep palpation. non-distended extremities: cool, with diminished pulses. pertinent results: admission labs: wbc-5.0 rbc-2.82* hgb-8.2* hct-26.7* mcv-95 mch-29.2 mchc-30.8* rdw-18.1* plt ct-232 neuts-81.9* lymphs-12.9* monos-3.9 eos-1.1 baso-0.2 pt-15.6* ptt-50.4* inr(pt)-1.4* glucose-168* urean-27* creat-3.1* na-147* k-3.1* cl-102 hco3-42* angap-6* calcium-8.9 phos-2.6* mg-2.3 alt-0 ast-8 ld(ldh)-105 ck(cpk)-8* alkphos-80 totbili-0.2 lipase-13 lactate-1.1 . discharge labs: 03:45am blood wbc-9.8 rbc-2.67* hgb-8.3* hct-26.8* mcv-100* mch-31.2 mchc-31.2 rdw-21.4* plt ct-180 03:45am blood pt-14.0* ptt-35.3* inr(pt)-1.2* 03:45am blood glucose-136* urean-27* creat-2.2* na-140 k-3.5 cl-108 hco3-24 angap-12 07:28am blood alt-24 ast-31 ld(ldh)-196 alkphos-122* totbili-0.2 04:53am blood calcium-8.7 phos-2.7 mg-1.8 06:50am blood caltibc-138* ferritn-428* trf-106* 12:32pm blood caltibc-144* ferritn-367 trf-111* 11:40am blood tsh-2.3 04:09am blood cortsol-7.3 06:56pm blood hiv ab-negative 04:14am blood type-art temp-36.7 rates-/28 tidal v-400 peep-5 fio2-40 po2-201* pco2-38 ph-7.43 caltco2-26 base xs-1 -assist/con intubat-intubated 07:55pm blood lactate-1.6 . micro 1:59 am urine source: cvs. **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 64 i tetracycline---------- =>16 r vancomycin------------ =>32 r . time taken not noted log-in date/time: 5:56 pm serology/blood taken from # 60614g. . 4:41 pm rapid respiratory viral screen & culture source: nasopharyngeal swab. **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. . **final report ** rapid plasma reagin test (final ): reactive. reference range: non-reactive. quantitative rpr (final ): reactive at a titer of 1:8. test performed by state lab. treponemal antibody test (final ): tp-pa reactive. test performed by state lab. . 5:29 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. sparse growth. klebsiella pneumoniae. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | klebsiella pneumoniae | | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- 4 s <=1 s ceftazidime----------- 4 s <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- 2 i <=0.25 s gentamicin------------ 4 s <=1 s meropenem------------- 1 s <=0.25 s piperacillin/tazo----- 32 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s . 3:54 am stool consistency: soft **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). . 12:32 pm sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (preliminary): commensal respiratory flora absent. pseudomonas aeruginosa. moderate growth. gram negative rod #2. moderate growth. . ct chest w/o 1. reaccumulation of large right loculated pleural effusion, simple in attenuation. the pleura appears is smooth but thikc; evaluation for infection is limited without contrast. 2. complete collapse of the right lower lobe and incomplete collapse of the right middle lobe. 3. nodular consolidative opacity at the right apex raises the possibility of an infectious process. 4. enlarged thyroid. consider outpatient thyroid function tests and ultrasound if needed. 5. atherosclerotic aortic and coronary artery calcifications. 6. persistent cholelithiasis, atrophic kidneys and splenic calcifications. ct head w/o contrast . 1. no acute intracranial hemorrhage. no mass effect. stable large territory chronic infarction mr is more sensitive in the detection of acute stroke. mr is more sensitive in the detection of sequelae of intracranial infarction. 2. small amount of fluid in the right maxillary sinus raises the possibility of sinusitis. ct head w/o contrast: 1. no acute hemorrhage, mass effect, large mass, edema, or acute infarction is noted. 2. stable large region of cystic encephalomalacia and volume loss, consistent with remote right mca territorial infarction. 3. no pathologic enhancement. . eeg : this is an abnormal portable eeg due to slowing and disorganization of the background rhythm and intermittent focal slowing in the left frontal and anterior sylvian regions. these findings suggest a possible focus of subcortical dysfunction in this area and an underlying moderate to severe encephalopathy. medications, toxic/metabolic disturbances and infections are common causes. there were no epileptiform discharges or electrographic seizures seen in this recording. . cxr : as compared to the previous radiograph, there is now complete opacification of the right hemithorax. the absence of mediastinal shift to the left suggests a combination of pleural effusion and atelectasis. the left lung shows unchanged apical thickening and a just minimal pleural effusion as well as a small retrocardiac atelectasis. focal parenchymal opacity suggesting pneumonia are not present. the left-sided central venous access line has been removed in the interval . cxr : the endotracheal tube measures 4.4 cm above the carina. the right pleural effusion and partial collapse of the right lung are unchanged since . the cardiac and mediastinal silhouette is stable. the left lung is well expanded. there is no pneumothorax. the right-sided pacemaker and lead is unchanged in position. brief hospital course: # altered mental status: the patient was initially brought in to be evaluated for possible confusion per his family. however on further questioning, he initially appeared to be at his relative (, nearly deaf, left hemiplegia, intermittently saying words with signficant stimulation but rarely oriented). an rpr was found to be mildy positive and neurosyphyllis was thought to be possibly contributing to his confusion. to this end a lumbar puncture under fluoroscopic guidance was pursued. however, due to decompensation (see below) the lp was not completed. given the risk of a repeat lp, under guidance from the infectious disease department, it was decided to treat him for presumed neurosyphyllis. he received 2 weeks of iv ceftriaxone, completed in house, with little improvement of his mental status after his arrest. after his arrest, the patients mental status became essentially unresponsive to any stimuli. repeat ct head and eeg showed no acute process. the patient could not receive an mri due to a pacemaker. in consultation with neurology, his new may be a result of some anoxic brain injury. . # pea arrest: the morning of his lumbar puncture, a cxr showed complete opacification of his right lung, likely indicating a significant mucous plug at that time. at , he has a large, chronic, loculated pleural effusion that compresses most of the right lung, leaving only a small section aerated. during his lumbar puncture procedure, the patient suffered a pea arrest and was down for approximately 5 minutes. he was resuscitated with cpr. as above, after the arrest, his mental status was essentially unresponsive. his ability to protect his airway was significantly decreased. after initial extubation after his arrest, he required frequent nasal trumpet suctioning to prevent recurrent mucous plugging. even with frequent suctioning, he had several further mucous plugging events with significant desaturations requiring acute suction. the last such event was a near respiratory arrest on the general medical floor requiring re-intubation. after lengthy discussion with his family, it was decided to place a tracheostomy to attempt to minimize further mucous plugging events and ease suctioning, as he was having significant nasopharyngeal trauma from nt suctioning. hyocamine tabs and mucomyst nebs were added to decrease and help clear secretions. he will require frequent suctioning and close monitoring of his airway to minimize further plugging events. the family was made aware that the tracheostomy may not prevent further events and that his overall mortality in the next year is significant. they feel strongly that the patient would want to continue living no matter what the cost. extensive discussions were held regarding goals of care and code status with no change in his full code status. the family's overall goal is to bring the patient home if at all possible. . # respiratory failure: as noted above, his last mucous plugging event resulted in reintubation. he is in the process of weening ventilatory support, currently on ps ventilation, 14/5, 40% with good respiratory mechanics. his ventilatory support should continue to be weened as tolerated with possible trach collar soon. of note, given his poor right lung, it is unlikely that the patient will ever have a satisfactory rsbi. sputum culture from grew pseudomonas and pan-sensitive klebsiella. the patient had no evidence of actual pneumonia at that time. it was felt that the pseudomonas was likely a colonizer given that the exact same strain has been isolated from sputum cultures months prior. the klebsiella was concurrently treated during his 2 week course of ceftriaxone as above. prior to discharge, a sputum culture was growing pseudomonas and one other gram negative rod. again, he had no other clinical signs of pneumonia so new antibiotics were not started. further follow of sputum culture should occur and if the patient decompensates, consideration of antibiotics treating pseudomonas should occur. . # pyuria: patient had a grossly positive ua. ceftriaxone and vancomycin were given initially. piperacillin-tazobactam was added and ceftriaxone discontinued when he became hypothermic and altered requiring icu transfer. he was ultimately found to have a vre urinary tract infection. he was treated with linezolid, with a recommended course of 7 days. . . # hypothermia: on the first hospital day the patient's temperature dropped to <96 farenheit. other vital signs were stable. given concominant leukopenia and positive ua, this was concerning for sepsis. blood cultures were sent, and warming blankets were placed. the patient was transferred to the intensive care unit for closer monitoring in the setting of likely sepsis, his antibiotic regimen was broadened to vancomycin/zosyn. his hypothermia improved. he has been hypothermic on his last several admissions. it may be that his physiologic response to infection is hypothermia rather than hyperthermia, or he is an outlier at the lower extreme of temperature at . on the floor after transfer out of the icu he initially needed a bearhugger to maintain temperatures >96 and cultures done at that time were negative. he eventually was able to maintain temperatures ranging 96-98 without the assistance of a bear hugger. . #. esrd: family reported episode of fistula bleeding the previous day. pressure dressing was in place on admission. hct was decreased, possible secondary to this. transplant surgery initially evaluated the fistula and determined that it was functional and ready for use. however, later on re-evaluation transplant surgery felt that his fistula needed revision prior to discharge. this was done and further hemodialysis should be avoided from his fistula for 2 weeks from . a tunnelled femoral hd line was placed for hd access until that time under ir guidance. dialysis was continued mwf schedule. midodrine was added to help improve his bp prior to dialysis to assist with volume removal and to combat possible autonomic dysfunction given wide swings in blood pressure. . enlarged thyroid: he had chest imaging to evaluate pulmonary function. an incidential finding of thyromegaly was noted. tfts are recommended as an outpatient. . #. hypernatremia: this was likely secondary to hypovolemia and resolved. . #. coronary artery disease: aspirin, and simvastatin were continued. . #. hypertension: lisinopril was continued. . #. type ii dm: oral hypoglycemics were initially held and iss given, but restarted as his blood sugars became elevated. his lantus was increased from 12 u qhs to 16 u qhs with effect. . . #. adrenal insufficiency- he is on 5mg prednisone daily at . there was an initial concern for sepsis, thus he got high dose steroids,however stim test was wnl. he was thus tapered, and returned to his home dose of 5mg daily prior to discharge. . #. access: he has poor vasculature. initial picc was placed which was pulled back to midline prior to discharge as it was coming out a little. . #. code status: full code status was confirmed with the family. medications on admission: senna prn prednisone 5 mg daily lisinopril 5 mg daily lansoprazole 30 mg daily simvastatin 10 mg daily aspirin 81 mg daily simethicone 80 mg cefazolin 2g hd protocol until insulin glargine 12 units qhs insulin lispro sliding scale tube feeds: renal full strength, 50cc/hr, 150cc q4h discharge medications: 1. insulin lispro 100 unit/ml cartridge : sliding scale subcutaneous amount delivered depends on blood sugar. 2. renal full strength : one y (150) cc every four (4) hours: at 50cc/hr. 3. b complex vitamins capsule : one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 4. folic acid 1 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. simvastatin 10 mg tablet : one (1) tablet po daily (daily). 6. folic acid 1 mg tablet : one (1) tablet po daily (daily). 7. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day). 8. sodium chloride 0.65 % aerosol, spray : sprays nasal tid (3 times a day) as needed for congestion. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q4h (every 4 hours) as needed for sob, wheeze. 10. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po qid (4 times a day) as needed for nausea, high residual. 11. b-complex with vitamin c tablet : one (1) tablet po daily (daily). 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 13. hyoscyamine sulfate 0.125 mg tablet, sublingual : one (1) tablet, sublingual sublingual qhs (once a day (at bedtime)). 14. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 15. midodrine 5 mg tablet : one (1) tablet po tid (3 times a day). 16. acetylcysteine 20 % (200 mg/ml) solution : five (5) ml miscellaneous q6h (every 6 hours) as needed for mucous. 17. prednisone 10 mg tablet : 0.5 tablet po daily (daily). 18. insulin glargine 100 unit/ml solution : nineteen (19) units subcutaneous at bedtime. 19. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 20. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection (2 times a day). 21. heparin flush (10 units/ml) 2 ml iv prn line flush mid-line, heparin dependent: flush with 10 ml normal saline followed by heparin as above, daily and prn per lumen. 22. sodium chloride 0.9% flush 10 ml iv prn line flush mid-line, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 23. fentanyl citrate (pf) 50 mcg/ml solution : 25-50 mcg injection q2h (every 2 hours) as needed for pain, agitation. discharge disposition: extended care facility: northeast - discharge diagnosis: primary recurrent urinary tract infection hypoxemic pea arrest respiratory failure anoxic brain injury/altered mental status neurosyphillis . secondary end stage renal disease diabetes hypertension peripheral vascular disease adrenal insufficiency discharge condition: hemodynamically stable tracheostomy in place, on ps ventilation 14/5, 40% non-responsive mental status (new ) afebrile discharge instructions: you were admitted to the hospital because you were confused, and had also been having some vomiting, and bleeding from your fistula. you were found to have an infection of your urine which was treated with antibiotics. in the setting of working up your confusion, a lumbar puncture was attempted. during this you had low oxygen levels and your heart stopped. this was likely due to mucous plugging. to attempt to prevent further plugging events, a tracheostomy was performed. your fistula was also surgically repaired and a tunnelled dialysis catheter was placed in your groin. . please call your doctor or return to the hospital if you experience confusion, shortness of breath, nausea, vomiting, diarrhea, headache, fever, chills, changes in your bowel movements, chest pain, or any other symptoms that are concerning to you. followup instructions: . provider: function lab phone: date/time: 2:40 provider: ,interpret w/lab no check-in intepretation billing date/time: 3:00 provider: . /dr. phone: date/time: 3:00 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours 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 insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis other bronchoscopy arterial catheterization laryngoscopy and other tracheoscopy temporary tracheostomy cardiopulmonary resuscitation, not otherwise specified revision of arteriovenous shunt for renal dialysis artificial pacemaker rate check diagnoses: end stage renal disease nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere anemia, unspecified urinary tract infection, site not specified toxic encephalopathy friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status peripheral vascular disease, unspecified candidiasis of mouth hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute respiratory failure cardiac arrest anoxic brain damage surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation infection with microorganisms without mention of resistance to multiple drugs late effects of cerebrovascular disease, hemiplegia affecting unspecified side cardiac pacemaker in situ streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] glucocorticoid deficiency hyperosmolality and/or hypernatremia other and unspecified coagulation defects diabetes with other specified manifestations, type ii or unspecified type, uncontrolled late effects of cerebrovascular disease, aphasia complications of transplanted kidney other complications due to renal dialysis device, implant, and graft foreign body accidentally entering other orifice background diabetic retinopathy mixed acid-base balance disorder diabetes with renal manifestations, type ii or unspecified type, uncontrolled other late effects of cerebrovascular disease, dysphagia neurogenic bladder nos shock, unspecified diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled dysphagia, unspecified neurosyphilis, unspecified foreign body in other specified parts bronchus and lung hypothermia not associated with low environmental temperature carrier or suspected carrier of other specified infectious organism 

Answer: The patient is high likely exposed to