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: heparin flush attending: chief complaint: hypotension major surgical or invasive procedure: thoracentesis history of present illness: 67 yo male with cad s/p cabg, chf ef 20%, htn, dm2, h/o uti, h/o cons bacteremia, ? hit, s/p trach/peg () presents as transfer from hospital with shock. patient was recently discharged from hospital on with flash pulmonary edema and was discharge to . he represented to on with signs of hypovolemic shock. on the evening prior to admission, patient had an episode of flash pulmonary edema and was given 80 mg iv lasix, with perihilar infiltrates on xray which resolved after diuresis. the following day he was found to be lethargic and was found to he hypotensive to 66/42. h was given 250 cc of fluid and transferred to the ed with a bp 80s/40s prior to transfer. . at , patient was noted to be febrile to 103.2 on . he was felt at the time to have sepsis to pneumonia with sputum growing gnr and pseudomonas. he was treated with /cipro/vanco adjust to renal function. he was treated with levophed and dopamine for maps 65. cr was noted to be 1.9 from a baseline of 1.1 which was felt to be contraction in the setting of diuresis and hypotension. total i/os for los was 1.89/590. patient was also noted to develop lle edema. plan was for patient to have leni performed, but this was not done prior to transfer. inr on admission was noted to be 2, but trended down to 1.6. plan was for patient to be started on lepeirudin, but this was not initiated prior to transfer. in regards to dm, home dose of lantus 20 u were continued. . in the icu, patient is on mechanical ventilation through a trach. he appears comfortable at this time. . review of sytems: limited due to patient on mechanical ventilation. past medical history: cad s/p cabgx3 - h/o vf arrest s/p icd placement; required explantation for mrsa pocket infection with reimplantation , s/p lead removal - mechanical , . , - ascending aorta repair c graft - chf (ef 20% per tte ) - high grade cons bacteremia in c/b high grade cons, vre bactermia while on vancomycin , s/p 4 weeks daptomycin and explantation of icd leads - pseudomonas uti s/p cefepime x 14 days, now pseudomonas uti s/p meropenem x 14 days - r lateral foot ulcer s/p debridement s/p zosyn x 14 days - dm2 c/b neuropathy, nephropathy, l bka - hep c (dx , 2.38 million iu/ml. seen by hepatology, note emphasizes deferring ifn/ribavirin tx for now given infections, etc.) - htn - hlp - pvd s/p l bka - hypothyroidism - h/o opiate dependence, ?benzo dependence - acute on chronic sdh, - h/o r scapula fx - h/o mrsa elbow bursitis, - h/o closed bimalleolar fx s/p repair, removal of hardware - ischemic bowel s/p small bowel resection and anastomosis on - s/p trach/peg social history: lives in , though has been in rehab for much of the past few months. former cab driver. social history is significant for the current tobacco use of 40 pack years. there is no history of alcohol abuse or recreational drug use. lives with common-law wife of 35 years who is a home health aid. . family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: general: trach, on ventilation, arouses to verbal and mechanical stimulation, and follows commands heent: sclera anicteric, mmm, + thrush neck: supple, jvp elevated to pinna, no lad lungs: quietlung sounds, crackles bilateral bases, no wheeze or rhonchi cv: regular rate and rhythm, loud mechanical click at aortic region, 3/6 sem, normal s1 + s2, abdomen: peg inplace, with mild erythema surrounding the site, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: + foley with yellow urine ext: left bka, with 2+ edema left greater than right, no erythema appreciate, 2 stage iii ulcers on sacral region pertinent results: 05:00pm admission labs wbc-9.7# rbc-3.75* hgb-10.5* hct-33.7* mcv-90 mch-28.1 mchc-31.3 rdw-17.0* plt ct-249 neuts-74.3* lymphs-19.6 monos-4.0 eos-1.8 baso-0.3 pt-19.8* ptt-40.2* inr(pt)-1.8* glucose-320* urean-62* creat-1.9* na-136 k-4.1 cl-98 hco3-30 angap-12 alt-30 ast-66* ld(ldh)-272* alkphos-100 totbili-0.9 albumin-2.6* calcium-7.8* phos-4.1 mg-3.2* mix temp-37.1 peep-12 fio2-100 po2-40* pco2-50* ph-7.39 caltco2-31* base xs-3 aado2-642 req o2-100 intubat-intubated lactate-1.3 03:54am blood wbc-6.8 rbc-3.23* hgb-9.2* hct-28.7* mcv-89 mch-28.6 mchc-32.2 rdw-17.8* plt ct-261 02:54am blood wbc-6.3 rbc-3.07* hgb-8.9* hct-27.2* mcv-89 mch-29.0 mchc-32.6 rdw-17.2* plt ct-218 02:54am blood neuts-72.8* lymphs-16.6* monos-5.8 eos-4.5* baso-0.3 03:51pm blood pt-37.2* ptt-71.6* inr(pt)-3.9* 04:42am blood glucose-176* urean-28* creat-0.9 na-133 k-3.6 cl-93* hco3-33* angap-11 03:52pm blood urean-29* creat-0.8 na-130* k-3.7 cl-88* hco3-33* angap-13 03:51pm blood glucose-207* urean-27* creat-0.9 na-129* k-3.9 cl-90* hco3-33* angap-10 02:40am blood probnp-9834* 05:48am blood type-art po2-112* pco2-50* ph-7.48* caltco2-38* base xs-12 discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:37 6.9 3.34* 9.7* 28.8* 86 29.1 33.8 16.8* 235 source: line-picc differential neuts bands lymphs monos eos baso atyps metas 05:10 68.2 21.0 7.1 3.2 0.5 source: line-picc basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 05:37 235 source: line-picc 05:37 43.7* 53.2* 4.7* glucose urean creat na k cl hco3 angap 05:37 861 36* 1.3* 127* 4.1 88* 32 11 . micro: blood cx no growth urine cx no growth urine legionella negative and c diff and stool studies negative x 2 sputum: respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. rare growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 2 s ciprofloxacin---------<=0.25 s gentamicin------------ 4 s meropenem------------- 4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s pleural fluid cytology negative for malignant cells pleural fluid: gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): no growth. fungal culture (preliminary): acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): reports: lenis:negative for dvt tte:well seated aortic valve mechanical prosthesis. moderate mitral regurgitation. symmetric left ventricular hypertrophy with severe global hypokinesis. compared with the prior study (images reviewed) of , the left ventricular cavity is slightly smaller and the estimated pa systolic pressure is lower. the other findings are similar. cxr: ct a/p: impression: 1. increase in bilateral pleural effusions since ct of , with increased bilateral consolidation and atelectasis. a rounded density involving the right middle lobe may represent rounded atelectasis, consolidation, or a combination of both. confirmation of resolution after treatment is recommended. 2. increased presacral and perirectal stranding with rectal tube in place. the findings may indicate proctitis. clinical correlation recommended. 3. hyperdense material in the nondistended gallbladder, may represent sludge, excreted contrast, or tiny stones. brief hospital course: 67 yo male with cad s/p cabg, chf ef 20%, htn, dm2, h/o uti, h/o cons bacteremia, antibody positive-hit, s/p trach/peg () who presented as a transfer from hospital with septic and cardiogenic shock. . #. shock: met sirs criteria by fever, tachycardia, and relative leukocytosis and required pressors for several days, treated initially with levophed and then dobutamine with concern for cardiogenic component. most likely source was pseudomonas pneumonia which was sensitive to ciprofloxacin. other blood cx, urine cxa nd c diff negative. he was initially treated with broad coverage abx which was narrowed to cipro for 15 day course for pseudomonas vap as below. also felt to be in cardiogenic shock and he was diuresed aggressively on lasix drip. repeat tte with ef 25%. diuresis as below for chf. bp normal over >72 hours off pressors with diuresis. #. mechanical : patient on warfarin with inr goal 2.5-3.5. arrived with subtherapeutic inr. we were unable to bridge with heparin given ? hit so bridged with argatroban with therapeutic inr on . inr will need to be closely monitoried and he may need increased coumadin dose since now will be off cipro and will have lowering of inr once discontinued. will need to restart argatroban if inr<2.5. coumadin dose stable at 5mg daily, decreased to 2 mg daily and was on hold the day of discharge given uptrending inr (while on 2.5mg daily), which was 4.7 at discharge. will need close monitoring since medications being adjusted and will be off cipro. . #. vap: psuedomonas on sputum cx associated with leukocytosis and sepsis with infiltrate so treated for 15 day course ciprofloxacin, last day . # chronic respiratory failure: was maintained on full vent support with intermittent trials of psv as tolerated but tended to tire at night. nifs low at lowest -`17 but slowly improved, -mid 30s and was tolerating trach mask most of day for several days prior to discharge, asking to be placed back on ac at night for fatigue. tolerated pmv and passed swallow eval for soft solids while pmv in place. was planning for discharge to on but had an episode of mucous plugging that required bagged ventilation. a bronchoscopy was performed which was unremarkable, and event was felt to be due to a mucous plug. patient remained stable from a respiratory prespective over the next 3 days. . # cuff leak: noted by respiratory with vt loss during ventilation. ip consulted and he had tracheostomy tube exchange over an exchange catheter to a portex 9.0 mm inner diameter, 12.3 mm outer diameter, cuffed tracheostomy tube, nonfenestrated with inner cannula. . # chf; ef 20% with evidence of volume overload on cxr. diuresed aggressively on lasix drip then lasix and metolazone. continued amiodarone at decreased frequency two times per week per cardiology recommendations. addition of captopril and lisinopril limited by hypotension in micu when pt concurrently being aggressively diuresed. plan is for patient to continue to have torsemide daily to goal even i/os. his weight on discharge is 104 kg, down from 119 kg on admission. he reponds to lasix 60-80 mg iv, but was held for na 150 and cr up to 1.3 on discharge. we advise continuing torsemide 40mg 1-2 times diaily for goal even i/os, until na worsens or cr increases above 1.2. patient has been considered a candidate for icd again in the future and is followed by a cardiologist at with whom he should follow up within the next 3-4 weeks. . # htn: hold antihypertensives for now. would restart captopril if bp allows. . # dm2: was on insulin drip initially for glucose control but transitioned to lantus at increased dose and hiss. . #. r pleural effusion: had 1.5l which was consistent with exudate by protein criteria. cytology negative and final cx will need follow up. patient will need ct follow up as below. . # r sided mass vs effusion: had pleural based infiltrate on cxr post- so ct obtained which was more consistent with effusion and likely atelectasis and lung collapse. should have imaging to eval for recurrent effusion based on symptomatology and a repeat ct chest in months to evaluate for interval change to follow a lung nodule and rule out enlarging mass. # abdominal pain: pt c/o relatively chronic abd pain which worsened during hosp course and was not related to peg. c diff negative. had loose stool on stool softeners but no frank diarrhea and guaiac negative. ct a/p with po contrast obtaiend with ? proctitis. rectal tube d/c'd prior to discharge as could be contributing factor. continued on oxycodone. consider long acting narcotic while taking po diet with pmv in place. . # hyponatremia: developed worsneing hyponatremia during hospital course felt to be secondary to med effect from over diuresis. . # asymmetric edema: lenis negative. likely chf since improved with diuresis. . # thrush: treated with nystatin . # acute renal failure: likely atn in the setting of sepsis in addition to poor forward flow from chf since improved with diuresis. bun and cr normalized with diuresis, and slightly elevated with diuresis to 36 and 1.3 respectively at discharge likely overdiuresis. . # right lung nodule: need follow up ct chest to document stability in 3 months time. . # fen: tfs until maintaining adequate po, diet as instructed when pmv in place; no ivf with fluid restriction # prophylaxis: coumadin, ppi # access: picc # communication: (girlfriend, hcp) , # code: full (discussed with hcp) medications on admission: amiodarone 200 mg po mwthf acetaminophen 325-650 mg q6h prn neurontin 300 tid aspirin 81 mg daily atrovent neb q2 prn cepacol lozenge prn coumadin 2.5 mg ? (unknown) dulcolax 10 mg pr prn lantus 25 u atorvastatin 40 mg daily lisinopril 2.5 mg daily aldactone 25 mg daily carvedilol 3.125 daily prevacid 15 mg prn - tylenol 650 prn, albuterol q1h prn, colace 100 po bid prn, oxycodone 10 q4h, senna 2 tabs po qhs, ativan 2mg iv qh discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash : five (5) ml mucous membrane (2 times a day). 2. polyvinyl alcohol 1.4 % drops : 1-2 drops ophthalmic q6h (every 6 hours). 3. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 4. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 5. gabapentin 300 mg capsule : one (1) capsule po tid (3 times a day). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : eight (8) puff inhalation q2h as needed for dyspnea. 8. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day). 9. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension : 15-30 mls po qid (4 times a day) as needed for gi upset. 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 12. oxycodone 5 mg/5 ml solution : five (5) ml po q4h (every 4 hours) as needed for pain. 13. amiodarone 200 mg tablet : one (1) tablet po 2x/week (mo,th). 14. insulin glargine 100 unit/ml solution : forty (40) units subcutaneous twice a day. 15. oxycodone 5 mg/5 ml solution : 5-10 mg po q3h (every 3 hours) as needed for pain. 16. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic q6h (every 6 hours) as needed for dry eyes. 17. insulin regular human subcutaneous 18. guaifenesin 100 mg/5 ml syrup : fifteen (15) ml po q6h (every 6 hours) as needed for cough. 19. warfarin 2 mg tablet : one (1) tablet po once a day: hold or titrate dose down for inr > 3.5 (goal inr 2.5-3.5). 20. torsemide 20 mg tablet : two (2) tablet po once a day: goal even i/0. will likely need to increase to dosing if/when patient running positive or weight trending up. discharge disposition: extended care facility: hospital - discharge diagnosis: primary diagnosis: shock, multifactorial related to sepsis from vap and cardiogenic shock secondary diagnosis: acute on chronic systolic chf, ef 25% mechanical aortic valve replacement antibody positive heparin induced thrombocytopenia abdominal pain discharge condition: on trach mask during the day, tolerating pmv; back on ac at night as needed for sob. afebrile. bp 130/50 o2 sats 100% on trach mask fio2 40% discharge instructions: you were admitted to the icu with low blood pressure related to pneumonia and decreased heart function. you were treated with antibiotics for your infection and lasix for your heart failure. you were also treated with argatroban for your mechanical valve while we were waiting for your coumadin level to be therapeutic. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow up with dr in weeks. call his office for an appointment ( follow up ct chest (1-2 months) to follow up possible right sided pulmonary nodule to document stability procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances thoracentesis arterial catheterization bronchoscopy through artificial stoma replacement of tracheostomy tube diagnoses: other iatrogenic hypotension abnormal coagulation profile acute kidney failure with lesion of tubular necrosis unspecified pleural effusion congestive heart failure, unspecified hyposmolality and/or hyponatremia severe sepsis unspecified acquired hypothyroidism unspecified viral hepatitis c without hepatic coma hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes candidiasis of mouth chronic kidney disease, unspecified heart valve replaced by other means pneumonia due to pseudomonas cardiogenic shock long-term (current) use of insulin septic shock pressure ulcer, lower back anticoagulants causing adverse effects in therapeutic use acute on chronic systolic heart failure diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled below knee amputation status gastrostomy status chronic respiratory failure attention to tracheostomy septicemia due to pseudomonas pressure ulcer, stage iii other diuretics causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to