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: levofloxacin attending: chief complaint: dyspnea, pneumonia major surgical or invasive procedure: et tube change arterial line placement right ij line placement ir-guided picc placement trach placement peg placement picc removed for fungemia single lumen picc placed history of present illness: 66 year-old woman with history of asthma, copd, dm, hypothyroidism, with recent history significant for worsening dyspnea over past three months, status post four courses of antibiotics and steroids for presumed copd exacerbation, presenting to hospital on with acute worsening dyspnea, intubated for respiratory distress, and transferred to for further management. as noted above, she has a history of worsening dyspnea over the past few months that has been treated with antibiotics and steroids. she presented to osh on with worsening dyspnea and had a fever to 103f, and was started on ceftriaxone/azithromycin () for pneumonia and copd exacerbation. she developed an increasing oxygen requirement, however, and initially required nasal canula (94% on 1 l o2) but later required face mask (86% on 15 l on ). her cxr, which initially was read as negative for infiltrate, progressively worsening, with increasingly prominent diffuse bilateral infiltrates, right greater than left. she also had a negative chest cta. with an oxygen requirement that was rising and worsening dyspnea, she was transitioned to vanc/zosyn/levo and then vanc/zosyn/ceftaz (; ceftaz started ; levo on ) because of an allergy to levofloxacin. it is unclear why she received double coverage for gram negatives. she was also given methylprednisolone ( dose 20 mg iv q8; then 80->60 mg iv q8 afterward). . on , she was admitted to the icu and intubated electively for hypoxia and sob. sputum culture grew staph aureas that was mrsa per report. influenza viral screen was negative. phenylephrine was started because of hypotension to sbps in the 80s after being intubated and starting on propofol (), which had to be uptitrated for sedation. she was transferred to on based on her family's wishes. . on arrival, her ventilator settings were vt 500cc, fio2 100%, peep 16. she was on phenylephrine at 0.6 and rapidly weaned off. her vs were 98.6 56 18 96%vent past medical history: copd asthma diabetes mellitus hyperlipidemia hypothyroidism gerd left breast cancer s/p lumpectomy h/ - syndrome (per pcp) social history: she does not smoke or drink. she lives with her husband. family history: non-contributory physical exam: vitals: t: 98 bp: 127/60 p: r: 18 o2: general: intubated, obese, arousable heent: ett, sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: soft inspiratory wheezes bilaterally, no rales or rhonchi cv: regularly irregular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs 11:36pm type-art temp-37.0 rates-18/5 tidal vol-500 peep-16 o2-100 po2-98 pco2-50* ph-7.42 total co2-34* base xs-6 aado2-565 req o2-93 intubated-intubated 11:22pm glucose-355* urea n-35* creat-0.9 sodium-141 potassium-4.2 chloride-104 total co2-27 anion gap-14 11:22pm calcium-8.1* phosphate-2.2* magnesium-2.5 11:22pm wbc-10.0 rbc-3.53* hgb-10.3* hct-29.9* mcv-85 mch-29.0 mchc-34.3 rdw-15.3 11:22pm plt count-289 11:22pm pt-12.4 ptt-24.9 inr(pt)-1.0 . 02:09pm blood ck(cpk)-30 ck-mb-notdone ctropnt-0.02* 10:41pm blood ck(cpk)-30 ck-mb-notdone ctropnt-0.01 03:00am blood ck(cpk)-28 ck-mb-notdone ctropnt-0.01 . 06:50am blood caltibc-178* ferritn-578* trf-137* 09:00pm blood fibrino-478* 04:13am blood ret aut-3.8* 04:15pm blood hapto-385* . 02:24am blood triglyc-303* 05:27am blood triglyc-70 . 04:41am blood tsh-0.61 . 05:10am blood %hba1c-8.9* . spep: trace abnormal band in gamma region based on ife (see separate report), identified as monoclonal igg kappa now represents, by densitometry, roughly 3% (150 mg/dl) of total protein. . upep: multiple protein bands seen, with albumin predominating based on ife (see separate report), negative for bence- protein. immunofixation, urine: no definite m protein seen. negative for bence- protein. . bal flow cytometry: there is an immuonphenotypically abnormal cd138+/cd56+ cell population that most likely represents the highly atypical plasmacytoid immunoblasts seen on -giemsa stained cytocentrifuge preparation of the submitted bronchioalveolar lavage fluid. the significance of this finding in the context of an acute viral illness is unclear. although a reactive process is favored, a lymphoproliferative disorder can not be ruled out. repeat sampling for cell block preparation and immunohistochemical studies is recommended if clinically indicated. . bal bronchial washings cytology: negative for malignant cells. many neutrophils, pulmonary macrophages, lymphocytes, and few multinucleated giant cells. rare fungal organisms present consistent with species. . 6:06 pm bronchoalveolar lavage gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): ~/ml oropharyngeal flora. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): no fungus isolated. . rapid respiratory viral screen & culture source: nasopharyngeal swab. 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. rapid respiratory viral antigen test (final ): this is a corrected report . respiratory viral antigen test is uninterpretable due to the lack of cells. positive for swine-like influenza a (h1n1) virus by rt-pcr at state lab. previously reported as respiratory viral antigens not detected . specimen screened for: adeno,parainfluenza 1,2,3 influenza a,b and rsv. refer to respiratory viral culture for further information. reported by phone to dr. . 12p . . 11:37 am urine source: catheter. legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . 6:30 pm sputum source: endotracheal. gram stain (final ): pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. sparse growth. pseudomonas aeruginosa cefepime-------------- 16 i ceftazidime----------- 32 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s meropenem------------- 1 s piperacillin---------- r tobramycin------------ <=1 s . 2:56 am blood culture source: line-a-line. blood culture, routine (preliminary): parapsilosis. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. sensitivities performed on request.. aerobic bottle gram stain (final ): reported by phone to dr. @ 0800am, . budding yeast. . , , , , , , , urine cx: yeast . cta chest : no evidence of pe. consolidation in the posterior segment of right upper lobe and superior segment of right lower lobe likely aspiration pneumonia. atelectasis is in the bases of the lungs. given the fact that there is no cardiomegaly or pleural effusions, diffuse ground-glass opacity is probably not cardiogenic in origin. could be resolving noncardiogenic pulmonary edema or drug reaction. reactive mediastinal lymphadenopathy. . ct chest : 1. overall improvement in extent of diffuse multifocal bilateral ground-glass opacities, with minimal areas of worsening opacities in the superior segment of the right lower lobe and in the left upper lobe. 2. unchanged mediastinal lymphadenopathy, likely reactive. 3. signs of anemia. 4. bulky left adrenal. fatty pancreas. tiny liver hypodensity too small to characterize. . cta chest : 1. no pulmonary embolism. 2. marked interval worsening of multifocal bilateral ground-glass opacities, with new areas of consolidation in the bilateral lower lobes, and right upper lobe, likely reflecting progression of infectious process. . ct chest : impression: multifocal bilateral airspace opacities in the lungs, grossly unchanged from the prior study. . tte : the left atrium and right atrium are normal in cavity size. suboptimal image quality agitated saline contrast injection at rest x 3 did not demonstrate early appearance of contrast in the left atrium. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. with normal free wall contractility.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be quantified. there is no pericardial effusion. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. no definite intracardiac shunt identified. . tte the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. impression: normal global and regional biventricular systolic function. no diastolic dysfunction or significant valvular disease seen. mild pulmonary hypertension. . tte : the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: no vegetations seen (suboptimal-quality study). normal global and regional biventricular systolic function. . ct head 1. no acute intracranial pathology. 2. air-fluid level seen in the sphenoid sinuses, which may be the result of long-term intubation or nasal feeding tube. . ct head : no acute intracranial process. if there is a high clinical concern for an infarct, an mri with diffusion is recommended. . abd x-ray : findings: a percutaneous feeding tube is present overlying the midabdominal region. a non-obstructive bowel gas pattern is visualized with no evidence of free intraperitoneal air. abnormalities within the lung parenchyma are seen to better detail on the recent chest ct of earlier the same date. . hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 04:00am 10.9 3.67* 10.7* 32.7* 89 29.1 32.5 16.9* 521* differential neuts lymphs monos eos baso 04:00am 76.3* 14.2* 5.3 3.6 0.7 chemistry renal & glucose glucose urean creat na k cl hco3 angap 04:00am 132* 76* 0.9 145 4.3 104 30 15 antibiotics vanco 08:16pm 23.6* brief hospital course: 66 year-old woman with history of asthma, copd, dm, hypothyroidism presenting to osh with acute on chronic dyspnea, treated with antibiotics for pneumonia and intubated for worsening hypoxia, and transferred for further management. # respiratory failure/pneumonia: she was intubated for worsening hypoxia on at the osh in the setting of pneumonia and worsening bilateral infiltrates. her course was notable for progressive worsening of her respiratory status during her osh hospitalization, along with development of bilateral infiltrates. at the time of transfer, her cxr, large a-a gradient, and low pao2/fio2 were thought to be consistent with ards/acute lung injury, and mechanical ventilation settings targeted low tidal volumes and high respiratory rate. however, despite this, her lung was compliant, with low peak inspiratory pressures. she was also very peep dependent. culture data from the osh eventually demonstrated mrsa in her sputum culture and she was initially managed with vancomycin/zosyn and then zosyn was discontinued, and she was given a course of solumedrol because of her history of question copd. a respiratory viral screen performed at the osh was negative and was repeated at . the initial dfa test was negative but the sample was sent to the state lab and there, it was positive for h1n1. the id service was consulted and recommended switching from vancomycin to linezolid and empirically completing a course of oseltamavir of note, she also underwent a repeat chest cta that was negative for pe and a tte with a bubble study that was limited in quality but negative for intracardiac shunt. she continued to require high peep with hypoxia if peep was lower than 10. diuresis was tried several times with minimal change in peep. linezolid was switched back to vancomycin given concern for lactic acidosis. id then recommended switching to meropenem to cover resistent pseudomonal vap which she continued for a 15 day course. a picc line was placed on for long term antibiotics. oseltamivir was discontinued on . vanco was discontinued. gradually able to wean down peep with improvement in bronchospastic episodes on increased sedation, and a trach was placed by ip on . sedatives eventually weaned off on and transitioned to fentanyl gtt and valium, which too were weaned off to a 25 mcg patch q72 hours - this should be weaned further at her facility under the direction of the accepting md. patient was transitioned to lasix iv boluses until cr and bun bumped, then prn to keep her i/os even. although sputum cx with persistence of pseudomonas, per id this was thought to represent colonization. pt finished her 15 day course of meropenem on . - single lumen picc was placed after a 3 day line holiday. # afib with rvr: patient developed af with rvr and hypotension. chads score=2. no evidence of pe on cta chest or right heart strain on echo; normal atria. she was started on hep gtt and amio-loaded. she remained in sinus rhythm for the majority of the rest of her stay aside from one further bout of afib. heparin was discontinued at time of trach placement; long-term anticoagulation was not started as she is considered low-risk s/p conversion. she was continued on amiodarone and asa. # volume overload: the patient was volume overloaded after about 1 week in the icu. lasix gtt was started to have a smoother diuresis as bolus doses (of 40mg iv lasix) made her transiently hypotensive. she was restarted on lasix gtt in setting of pressors, which were eventually weaned off. she was then transitioned to iv lasix boluses at 160mg iv tid until cr and bun bumped, then transitioned to prn lasix boluses to keep i/os even. of note, she was on acetazolamide for a few days due to metabolic alkosis but this was discontinued as bicarb normalizing. - please give iv lasix 80-160mg prn to keep fluid balance even. # fungemia: patient began to spike fevers almost one month into her hospitalization. she was started on oral fluconazole on due to persistent yeast-positive urine cultures despite changing out foley catheters. rij placed was pulled . however, blood cultures from a-line grew out yeast (presumptively not c. albicans) on ; her a-line and picc were pulled. id was re-consulted and recommended switching to micafungin. ophthalmology was consulted and did not see evidence of endopthalmitis. tte was suboptimal but without e/o endocarditis; id did not think tee needed. as blood cx grew c. paraipsilosis, changed to fluconazole iv to complete 14-day course of antifungal (last dose ). repeat blood cultures including mycolytic cultures showed no growth to date up until . # left arm weakness: patient was noted to be moving all extremities except the left upper voluntarily on . concern was for emoblic event given af as well as fungemia. ct head was done which showed no acute process and a tte was without vegitations. pt later observed to be moving all 4 extremities and withdrawing to painful stimuli in l arm so no further work-up pursued. # vaginal bleeding: she was noted to have vaginal bleeding after a week in the hospital. she was evaluated by ob gyn who could not find evidence of further bleeding. a pelvic ultrasound was a very limited study but did not find any pathology. she should follow up as an outpatient with her ob/gyn for further workup. # hypertriglyceridemia: tg elevated to 303 in setting of propofol gtt. pt initially switched to fentanyl and midazolam with improvement in tg. she was changed back to propofol for vent weaning with continued improvement and subsequent normalization of tg prior to discontinuation. # atyical bal pathology: tissue from bronch done on showed atypical plasmacytoid immunoblasts with abnormal cd138+/cd56+ cell population on flow cytometry. significance unclear in in the context of an acute viral illness and a reactive process was favored, although a lymphoproliferative disorder could not be ruled out. repeat bronch on with path read of "lymphocytes, alveolar macrophages, neutrophils and rare plasma cells with insufficient tissue for immunohistochemical characterization"; cytology negative for malignant cells. # diabetes: required insulin drip temporarily for elevated blood glucose but transitioned back to iss with glargine with good control. # hypothyroidism: continued levothyroxine. # communication: patient. husband is (h). son is (c) medications on admission: singulair 10 mg qhs prevacid 30 mg daily levothyroxine 100 mg daily d flonase 2 sprays eat nostril daily advair 500/50 on inh albuterol nebs prn janumet (metformin and sitagliptin) discharge medications: 1. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 3. ipratropium bromide 17 mcg/actuation aerosol sig: 6-8 puffs inhalation q4h (every 4 hours). 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q8h (every 8 hours) for 1 days: last dose on . 7. fluconazole in saline(iso-osm) 400 mg/200 ml piggyback sig: four hundred (400) mg intravenous once a day for 12 days: last dose on . 8. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours) for 2 days: please remove am of . 9. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours) for 3 days: please place . 10. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 11. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 12. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for sores. 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever. 14. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 15. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) ml po bid (2 times a day): hold for loose stools. 16. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 17. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed for constipation. 18. insulin glargine 100 unit/ml cartridge sig: forty (40) units subcutaneous once a day. 19. insulin regular human 300 unit/3 ml insulin pen sig: sliding scale as below subcutaneous every six (6) hours: adjust as needed 0-60: amp d50, 61-80: 0 units, 81-120: 9 units, 121-160: 12 units, 161-200: 15 units, 201-240: 18 units, 241-280: 21 units, 281-320: 24 units, 321-360: 27 units, 361-400: 30 units, > 400: notify m.d. . 20. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). discharge disposition: extended care facility: - - discharge diagnosis: primary - h1n1 (swine flu) pneumonia. - superinfection with mrsa pneumonia. - pseudomonas ventilator-associated pneumonia. - parapsilosis fungemia/line infection. secondary - copd/asthma - diabetes mellitus - hyperlipidemia - hypothyroidism - gerd - - syndrome - left breast cancer s/p lumpectomy discharge condition: stable on vented trach discharge instructions: you were transferred from another hospital for further management of copd exacerbation and pneumonia requiring intubation. you likely had swine flu which was complicated by mrsa pneumonia. you later also developed a pseudomonas pneumonia. you had a complicated icu course but your ventilator was able to be weaned down gradually. given your continued need for respiratory support, however, a tracheostomy was placed and a peg-tube in your stomach for nutrition. lastly, you were treated for a fungal blood infection. as you are more stable now, you are being discharged to a rehab for further care. of note, you had an episode of vaginal bleeding. however, you were examined by ob-gyn with a negative pelvic ultrasound and no evidence of any more bleeding. you should follow up with ob-gyn as an outpatient for further evaluation. antibiotic courses are as follows: - meropenem (last dose ) - fluconazole (last dose ) most of your other medications were changed. please refer to your new medication list and take all medications as prescribed. please call your doctor or come to the ed if you develop chest pain, difficulty breathing, fevers >101, dizziness, loss of consciousness, bleeding, or any other concerning symptoms. followup instructions: please follow up with your pcp, , following your discharge from rehab. his office number is . please also schedule follow-up with ob-gyn on discharge from rehab. the office number at is . procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more fiber-optic bronchoscopy percutaneous [endoscopic] gastrostomy [peg] arterial catheterization temporary tracheostomy closed [endoscopic] biopsy of bronchus diagnoses: esophageal reflux congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism atrial fibrillation personal history of malignant neoplasm of breast pure hyperglyceridemia other and unspecified hyperlipidemia acute respiratory failure methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site infection and inflammatory reaction due to other vascular device, implant, and graft chronic obstructive asthma with (acute) exacerbation acute systolic heart failure ventilator associated pneumonia other specified noninflammatory disorders of vagina pseudomonas infection in conditions classified elsewhere and of unspecified site other and unspecified mycoses acute infective polyneuritis long-term (current) use of aspirin methicillin resistant pneumonia due to staphylococcus aureus influenza with other manifestations 

Answer: The patient is high likely exposed to