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: aspirin / percocet / codeine / ambien / nutren pulmonary attending: chief complaint: respiratory failure major surgical or invasive procedure: intubation to respiratory failure bronchoscopy history of present illness: patient is an 84 yo female with history of copd, recurrent aspiration pna, mat, pvd s/p left femoral-peroneal bypass, htn, cad presented initially to on with worsening dyspnea. pt has had an extended hospital course, beginning in when she was admitted to on 2 occasions with respiratory distress, thought due to copd flare and aspiration pneumonia. most recently patient was discharged from on with what was thought to be copd flare and aspiration pneumonia. during this hospital course, pt had a failed speech and swallow evaluation with silent aspiration (no cough reflex). she was also transferred to the micu for increased respiratory distress, but did not require intubation. the patient was discharged from this hospitalization with ng tube in place, as she refused peg tube placement. . upon most recent discharge, patient was discharged to rehab. from here, on , she was admitted to hospital for re-aspiration pneumonia (unclear when ngt was d/ced) which progressed to respiratory failure requiring intubation. pt was discharged from caritas to rehab facility on high dose steroid taper. . over the following 48 hours post-discharge, patient had worsening dyspnea, increased oxygen requirement to 6l nc with desaturations into the 80's. she given methylprednisolone and lasix 40 iv x2, as dyspnea was thought related to chf. pt was then brought to for planned cardiac catheterization. however, pt had increasing respiratory distress in transit, requiring bipap. she was initially admitted to the ccu team. initially pt was treated with prednisone 20mg daily and nebulizers. morning after admission, the patient had increasing respiratory distress on bipap, with an abg of 7.34/61/67, and she was subsequently intubated. she was started on solumedrol 60mg iv q8hr, vancomycin, levofloxacin and flagyl. pulmonary was consulted and performed a bronchoscopy on that demonstrated a large amount of mucous and ?contrast/aspiration material that was suctioned out. . she has remained hemodynamically stable, and respiratory status has remained stable on vent. other notable hospital course events include pt noted to be guaic + on exam, hct has remained stable. patient was extubated on . she was transferred from micu to ccu step down for further care. past medical history: 1)asthma > 5 hospitalization with no history of intubations. she has been on steroids since the beginning of . prior to this, she had been steroid free for the past 2 years. 2)hypertension. 3)steroid induced hyperglycemia. discharged on insulin following her admission. 4)peripheral vascular disease, status post left fem-peroneal bypass in 5)multi-focal bacterial pneumonia. 6)chronic obstructive pulmonary disease- pft - fvc 61% pred, fev1 56% pred, fev1/fvc 92%, reduced fvc related to gas trapping, ~400 cc worse than pft from one year ago. 7)multi-focal atrial tachycardia. 8)oral thrush. 9)question left hilar mass. social history: distant tobacco use. occasional alcohol use. the patient was living with 24 hour home health aide until hospitalization. since then has been a resident at rehab facility. family history: asthma in her father physical exam: vitals: tm: 98.0 tc:96.9 , bp 156/91, range: 142/156/71-91 hr 80, 98% on 2l nasal canula gen: a&ox4,wnwd,responsive to commands. heent: ncat,perrla, eomi, 2mm pupils, no rhinorrhea or excessive lacrimation cv: systolic murmur best appreciated over r pul area, jvp normal, no jvd pulm: coarse lung sounds bilaterally much improved since last exam, diffuse expiratory rales abd: protuberant, soft, nondistended, nontender. gu: foley catheter patent & draining 180cc last hour extrem: warm & well perfused, 1+ pitting edema on r le. dp pulse 1+. skin: abd bruising consistent with heparin administration, punctate erythematous lesions (h/o zoster) r lumbar region in dermatomal distribution. pertinent results: 6:31p ck,cpis,tnt added / picc 148 106 124 agap=10 -------------< 223 4.9 37 1.4 ck: 8 mb: notdone trop-*t*: 0.06 comments: ctropnt > 0.10 ng/ml suggests acute mi ca: 8.7 mg: 2.6 p: 4.0 94 11.7 \ 8.5 / 266 d / 26.5 \ n:94.8 band:0 l:3.6 m:1.5 e:0.1 bas:0.1 comments: verified hypochr: 2+ anisocy: 3+ poiklo: 1+ macrocy: 2+ microcy: 1+ ovalocy: occasional tear-dr: occasional comments: manual plt-est: normal pt: 11.4 ptt: 21.2 inr: 1.0 follow up labs: 04:15am blood wbc-4.0 rbc-3.38* hgb-10.5* hct-31.6* mcv-94 mch-31.2 mchc-33.4 rdw-18.5* plt ct-196 09:22pm blood neuts-94.9* lymphs-4.1* monos-0.7* eos-0.2 baso-0.1 04:15am blood plt ct-196 04:15am blood glucose-239* urean-44* creat-1.1 na-138 k-3.5 cl-107 hco3-20* angap-15 04:15am blood probnp-pnd 01:21am blood caltibc-233* vitb12-1029* folate-greater th ferritn-557* trf-179* 09:30am blood vanco-24.9* 01:42pm blood type-art po2-96 pco2-32* ph-7.44 caltco2-22 base xs-0 08:25am blood type-art po2-67* pco2-61* ph-7.34* caltco2-34* base xs-4 micro: 5:34 pm bronchial washings gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): 10,000-100,000 organisms/ml. oropharyngeal flora. staph aureus coag +. 10,000-100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s 10:00 am stool consistency: soft source: stool. **final report ** clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative. for following micro: if no organism noted, culture is negative to date. stool clostridium difficile toxin assay-final inpatient blood culture aerobic bottle-pending; anaerobic bottle-pending inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient rapid respiratory viral screen & culture rapid respiratory viral antigen test-final; viral culture-preliminary inpatient bronchial washings gram stain-final; respiratory culture-final {staph aureus coag +}; legionella culture-final; fungal culture-preliminary {yeast} inpatient sputum gram stain-final; respiratory culture-final inpatient urine urine culture-final relevant imaging: 1) cxray (): no new areas of opacity are identified. there is continued opacity of the left retrocardiac region, which is stable in comparison to multiple prior studies. 2) ct chest w/o contrast (): (1) left lower lobe atelectasis likley due to mucus obstruction of the left lower lobe bronchi with several areas of barium aspiration. these findings as well as multiple small consolidations suggest recurrent aspirations as a possible cause of the patient's pneumonia. 2) cardiomegaly. significant coronary artery calcifications, aortic valve and mitral annulus calcifications. 3) multiple sub-cm mediastinal lymph nodes most likely reactive. 3)echo ():the left atrium is normal in size. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. compared with the prior study (images reviewed) of , right ventricle is now smaller and more vigorous. leni: impression: no evidence of dvt involving the right lower extremity. cardiology report ecg study date of 9:20:12 am ectopic atrial rhythm. right bundle-branch block. compared to the previous tracing no significant change. oropharyngeal videofluoroscopic swallowing evaluation evaluation: an oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with radiology. nectar-thick liquid, honey thick liquid, pureed consistency barium, one ground cookie coated with barium and one half cookie coated with barium were administered. results follow: oral phase: bolus formation was mildly reduced with mildly prolonged mastication of the solid consistencies. bolus control was moderately reduced with premature spillover to the pyriform sinuses and laryngeal vestibule before the swallow. oral transport was also prolonged mild tongue weakness and tongue pumping. the pt also appeared to have mildly reduced base of tongue retraction, but the residue on the posterior tongue may also have been the result of severe dry mouth. oral transit times were mildly prolonged with a mild to moderate amount of oral residue after all consistencies. pharyngeal phase: there was a mild to moderate delay in swallow initiation with all consistencies given. palatal elevation and laryngeal elevation appeared wfl, however laryngeal valve closure was mildly reduced. the pt did achieve complete epiglottic deflection with all consistencies given. pharyngeal transit was timely with adequate bolus propulsion, and no significant pharyngeal residue was seen immediately after any consistency. pharyngoesophageal sphincter opening appeared wfl at the height of the swallow. aspiration/penetration: the pt penetrated the thin and nectar thick liquids before the swallow the premature spillover and swallow delay. the pt penetrated to the level of the vocal cords, but had complete vocal cord closure before initiation of the swallow, preventing aspiration before the swallow. she cleared the majority of the penetration during the swallow, but the oral residue spilled to the valleculae and then over into the laryngeal vestibule / airway after the swallow. the aspiration was silent, or without coughing. cued coughs were effective, but the pt reported she felt sob after cued coughs. the aspiration after the swallow occurred with all liquids consistencies (thin, nectar and honey). the pt did not aspirate the purees or solids on this exam, but she did have significant residue on the base of her tongue that she could not consistently trigger a repeat swallow to clear. the risk for aspiration of this material was judged to be minimal, but there is a risk if her respiratory status declined over the course of po intake. treatment techniques: a chin tuck was attempted to prevent the aspiration with the liquid consistencies. it reduced the penetration before the swallow, but increased the amount of the oral residue that then spilled into the pharynx / airway after the swallow. cued coughs were effective, but resulted in sob. repeat swallows were most effective at clearing the oral residue, but she could not consistently trigger the repeat swallow. summary: the pt presents with a mild to moderate oral and pharyngeal dysphagia with more significant impairments compared to the video swallow completed here in . she is now consistently aspirating all liquid consistencies after the swallow which cannot be prevented. the pt has a peg tube in place, but has a strong desire to take pos for her quality of life. solid consistencies were not aspirated today, but there is a mild to moderate amount of oral /base of tongue residue that sits in the valleculae after the swallow. when she is able to trigger a repeat swallow, this material is fully cleared, but she cannot always trigger the second swallow. this material did not build up over time and she was given several trials of multiple bites of puree and cracker during the video swallow today. there is however a very minimal risk for aspiration of this material after the swallow, although not seen today. given her strong desire to take something po, it is recommended she begin trials of solid food only (purees through soft consistency solids are safe) once discharged to rehab where she can be supervised by a speech-language pathologist. she should be cued to take a repeat swallow after each bite, but will not always be able to take the repeat swallow. it will be crucial that she takes the repeat swallow at the end of the trial before lying back down. the amount the pt will be able to take by mouth with be very limited, as it is very hard to take a large amount of solids without liquids. she should be monitored closely, as her po intake may need to be adjusted if her overall status changes. recommendations: 1. suggest the pt continue to receive her primary means of nutrition, hydration and medication via the peg tube in place. 2. when the pt is d/c'd to rehab, she can have trials of po with speech language therapy only if: a) she takes purees, ground solids or soft consistency solids only b) no liquids! c) she is cued to take a repeat dry swallow after every bite. she will not be abe to consistently take a 2nd swallow, but she must take a second swallow at the completion of the po trial before lying down. d) her cxrs and breath sounds can be monitored closely and regularly to monitor for any changes. 3. pills via the peg tube. 4. if there are any changes in her cxr or there are clinical signs of aspiration, po intake will need to be stopped and the pt will need to return to an npo status with tube feedings only. these recommendations were shared with the patient, the nurse and the medical team. brief hospital course: ms. is an 84 yo female with severe copd, mat, pvd s/p left femoral-peroneal bypass, htn, aspiration pna who presented with worsening dyspnea and is currently s/p extubation () and peg placement (). . 1)aspiration pneumonia: on the morning after admission, the patient had increasing respiratory distress on bipap, with an abg of 7.34/61/67, and she was subsequently intubated. she is currently s/p extubation on . a bronchoscopy on demonstrated a large amount of mucous and contrast/aspiration material that was suctioned out. her bal grew out mrsa. she was initially started on vancomycin, ceftriaxone, and flagyl for aspiration pneumonia. infectious disease was consulted and per their recommendations both ceftriaxone and flagyl were d/c'ed. she is currently day 11 of a 14 day course of her vancomycin. given her history of aspiration pneumonia a peg tube was placed on and is currently being used for feeding. her ngt was removed (which she had in place prior to admission). a video swallow was performed on recommending that the patient continue to receive her primary means of nutrition, hydration and medications via the peg tube. she aspirates all liquid consistencies and she should be maintained on a solid diet. patient remains afebrile during this hospital course. ms. was started on a prednisone taper, initially at 60mg, now on 40mg daily. dose is being tapered by 5 mg q3 days. she has also been receiving albuterol, atrovent and advair nebulizers q6h, q1h prn. . 2)copd exacerbation: copd also likely cause of respiratory failure. she initially was on ipratropium and albuterol nebs on prior admission. her albuterol was changed to xopenex given her tachycardia. she was also placed on fluticasone mdi. her oxygen saturation remained in the high 90's on ra. cardiac 3)cad: pt had mild elevation of cardiac enzymes on admission likely due to demand ischemia, no acute changes on ekg. she is currently on plavix and lipitor. echo demonstrated normal systolic function. ms. was not placed on a beta blocker in the context of her asthma & copd. she also reports an aspirin allergy and therefore was not started on asa. . 4)pump: patient has history of chf and was being treated as an outpatient with lasix 40mg daily. echo during this admission demonstrated normal systolic function with an ef>65%. cxr suggested a combination of worsening heart failure and pneumonia. her i/o's were closely monitored to make sure she was kept negative. she was diuresed appropriately with lasix since she had clinical signs of fluid overloads. . 5)rhythm: patient has history of mat. she had several episodes of svt during her admission. she initially came to the ccu on verapamil but was then started on iv diltiazem and responded appropriately. she was then transitioned from iv to po cardizem 360mg daily. . 6)lower extremity edema: she had pedal edema initially on admission. since there was some asymmetry (l>r)an u/s was done to r/o a dvt, which was negative. edema was likely secondary to fluid overload. she was diuresed with lasix and responding appropriately. . 7)normocytic anemia: guaiac positive on exam but lavage negative. suspect chronic gi blood loss. high dose steroids may predispose to acute gib. hct was stable throughout her hospital stay. . 8)renal insufficiency: bun was elevated on admission likely due to volume depletion. given guaiac positive stools, a gib was also included in the differential, although unlikely. . 9)resolving herpes zoster: resolving infection but patient continued to have intolerable pain. she was started on standing tylenol 650mg q4h and neurontin for neuropathic pain. . 10)insomnia: per pt she takes ambien daily at home. she was initially continued on ambien but the team felt that she became extremely drowsy and sometimes not arousable. for this reason her ambien was changed to trazadone 50 mg qhs. . 11)fen: peg tube placed and was started on tube feeds and tolerated well. did well with promote with fiber, but got diarrhea from nutren pulmonary. . 12)prophylaxis: heparin sc, ppi for high dose steroids and ng tube. pneumoboots. . 13)code: full medications on admission: verapamil 120mg po q6h nexium 40mg qam fexofenadine () 60mg daily montelukast (singulair) 10mg po daily levalbuterol nebs q4h esomeprazole (nexium) 40mg po daily ipratropium 0.02% nebs q4h allopurinol 100mg daily clopidogrel 75mg po daily furosemide 40mg daily nitroglycerin patch 0.6mg q12h, then off q12h calcium250mg/vitamin d prednisone 20mg po daily insuling humalog ss, nph 10 qam gabapentin 300mg tid zolpidem 5mg po qhs prn colace 100mg prn bisacodyl 10mg pr daily prn fleets enema pr daily prn nitropatch discharge medications: 1. montelukast 10 mg tablet : one (1) tablet po daily (daily). 2. fluticasone-salmeterol 250-50 mcg/dose disk with device : one (1) disk with device inhalation (2 times a day). 3. gabapentin 300 mg capsule : one (1) capsule po bid (2 times a day). 4. tiotropium bromide 18 mcg capsule, w/inhalation device : one (1) cap inhalation daily (daily). 5. pramoxine-mineral oil-zinc 1-12.5 % ointment : one (1) appl rectal 1-5x qd () as needed for hemmorhoidal pain. 6. levalbuterol hcl 0.63 mg/3 ml solution : one (1) inhalation q6h (every 6 hours). 7. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 8. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 9. allopurinol 100 mg tablet : one (1) tablet po every other day (every other day). 10. acetaminophen 160 mg/5 ml solution : po q4h (every 4 hours) as needed for pain. 11. insulin glargine 100 unit/ml solution : twenty (20) units subcutaneous at bedtime: qhs - may increase for elevated blood sugars/taper for decreased blood sugars 12. prednisone 20 mg tablet : two (2) tablet po daily (daily): please taper by 5 mg q3d to eventual goal of off prednisone. 13. vancomycin in dextrose 1 g/200 ml piggyback : one (1) dose intravenous q48h (every 48 hours) for 4 days: last day . 14. diltiazem hcl 90 mg tablet : one (1) tablet po every six (6) hours. 15. fexofenadine 60 mg tablet : one (1) tablet po twice a day. 16. calcium 500+d 500-400 mg-unit tablet, chewable : one (1) tablet, chewable po twice a day. 17. colace 100 mg capsule : one (1) capsule po twice a day. 18. senna 8.6 mg capsule : one (1) capsule po once a day as needed for constipation. 19. dulcolax 5 mg tablet, delayed release (e.c.) : tablet, delayed release (e.c.)s po once a day as needed for constipation. 20. nitroglycerin transdermal 21. fluticasone 220 mcg/actuation aerosol : two (2) puff inhalation twice a day. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: respiratory failure aspiration with mrsa pneumonia congestive heart failure with demand ischemia right leg swelling with no dvt normocytic anemia acute renal failure, resolved herpes zoster with neuralgia steroid induced hyperglycemia discharge condition: stable, on room air and ready for discharge. discharge instructions: 1) resume medications as indicated in discharge instructions. 2) please weigh patient every morning, call your doctor if weight > 3 lbs and adhere to 2 gm sodium diet. 3) please schedule follow-up with your primary care physician. 4) based on studies done at , you are now restricted to a solid food diet. please stay away from all liquids until cleared by speech and swallow at . 5) if you experience any chest pain, pressure, dizziness or any other concerning symptoms, please return to the ed. followup instructions: please follow-up with your pcp (dr. within 1 week of discharge from rehab. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus percutaneous [endoscopic] gastrojejunostomy transfusion of packed cells diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified infection with microorganisms resistant to penicillins peripheral vascular disease, unspecified chronic kidney disease, unspecified acute respiratory failure other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus methicillin susceptible pneumonia due to staphylococcus aureus chronic obstructive asthma with (acute) exacerbation volume depletion, unspecified herpes zoster without mention of complication 

Answer: The patient is high likely exposed to