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: history of present illness: the patient is a 76-year-old female with multiple medical problems who was transferred from for management of congestive heart failure, acute on chronic renal failure, and mental status changes. the patient originally presented on with complaints of increasing shortness of breath, nonproductive cough, and altered mental status. the husband stated that the patient was well until two days prior to admission to when she began feeling weak. per report, she was unable to arise from the chair. she had increased pain at her decubitus ulcer site and some watery diarrhea from her colostomy site. this was associated with some shortness of breath, but the husband denied any focal pain in the chest or abdomen of the wife. the patient had a baseline creatinine of 1.4 in early , and her creatinine was 1.9 on admission to which bumped to a high of 2.9 on (discontinued lasix on ) after aggressive diuresis and then fell back to 2.5 on transfer. renal consult was obtained on who suggested a prerenal azotemia secondary to dehydration versus congestive heart failure. they recommended stopping diuresis with lasix, stopping the patient's ace inhibitor, and providing gentle hydration. the patient was noted to have a urinary tract infection at the time of discharge and was started empirically on rocephin at . it did not appear that she demonstrated an increase white blood cell count nor did she become febrile. her original chest x-ray at demonstrated a left lower lobe consolidation (atelectasis versus pneumonia), and she was continued on rocephin therapy. neurology was consulted for mental status changes who suggested checking a head ct which was without evidence of bleed or mass. other suggestions including an eeg and mri were not performed at the time. in addition, the patient was noted to have a low hematocrit at with normal iron studies, normal b12, and folate. her hematocrit stayed stable at 26-27. she had an elevated inr of 6.0 on , and therefore, her coumadin was held. the patient was subsequently transferred to as it became difficult to manage her congestive heart failure in the setting of acute on chronic renal failure and secondary to mental status changes. past medical history: 1. fournier's gangrene in (complicated by a diverting colostomy, complicated with cerebrovascular accident, right-side clot, right toe gangrene, right bka). 2. diabetes mellitus. 3. coronary artery disease. 4. congestive heart failure. 5. chronic renal insufficiency. 6. chronic anemia. 7. mrsa. 8. small bowel obstruction with subsequent colostomy. 9. chronic atrial fibrillation. 10. patent foramen ovale. 11. right bka. allergies: heparin, percocet, oxycodone. of note, the patient is exquisitely sensitive to narcotics with significant decrease in respiratory drive with as little as 1 mg morphine iv. social history: the patient is a resident of the nursing home of ................. she is married with no children and has a very attentive husband. she denied any alcohol or tobacco use. review of systems: on transfer, the patient reported generalized weakness times a few days but had somewhat improved. she denied any headache, dizziness, but was very thirsty. she denied rhinorrhea, sore throat, but complained of dry cough. she had no pleuritic chest pain. she had some shortness of breath but improved. she had no abdominal pain. she had some watery stool over the last few days. no dysuria. no lower extremity edema. she had a positive weight gain within the last few days. physical examination: vital signs: temperature 97.0??????, heart rate 84, respirations 20, oxygen saturation 91% on room air, 99% on 3 l oxygen by nasal cannula. general: the patient was lying still. she was moderately ill appearing. she was in no acute distress. heent: normocephalic, atraumatic. extraocular movements intact. pupils equal, round and reactive to light. oropharynx dry. no wheezing. neck: supple. no lymphadenopathy. jvp at 7 cm. cardiovascular: irregularly, irregular. there was a 2/6 systolic murmur heard best at the sternal border. lungs: few crackles at the bilateral bases. abdomen: positive bowel sounds. colostomy in place. soft, nontender, nondistended. no masses. no hepatosplenomegaly. extremities: there were 2+ pulses in the upper extremities. she had decreased pulse in left lower extremity. right bka clean and intact. no erythema. skin: occasional ............... no rash. neurological: the patient was alert and oriented times three. she was sleepy but easily arousable. she moved all four extremities. back: there was a grade 3 sacral decubitus, packed, good granulation tissue. there was a single area of 1.5 cm of mild redness around the sacral decubitus. no discharge. no palpable abscess. perineum: no discharge. no erythema. no palpable fluid collection or abscess. medications at home: nph 18 u subcue q.a.m., 10 u subcue q.p.m., coumadin 5 mg p.o. q.d., epogen 5000 u subcue twice a week, imdur 60 mg p.o. q.d., paxil 20 mg p.o. q.d., xanax 0.25 mg p.o. b.i.d., prevacid 30 mg p.o. q.d., multivitamin 1 tab p.o. q.d., duragesic 15 mcg transdermal patch to be changed q.72 hours, accupril 10 mg p.o. q.d. medications on transfer: paxil 20 mg p.o. q.d., multivitamin 1 tab p.o. q.d., calcium carbonate 500 mg p.o. t.i.d., vitamin c 500 mg p.o. q.d., vitamin d 400 mg p.o. q.d., senna 1 tab p.o. q.d. p.r.n., epogen 5000 u twice a week, imdur 30 mg p.o. q.d., duragesic patch 50 mcg transdermal to be changed q.72 hours, rocephin 1 g q.24 hours, milk of magnesia p.r.n., dulcolax p.r.n., regular insulin sliding scale. laboratory data at the outside hospital: on sodium was 143, potassium 5.6, chloride 109, bicarb 24, bun 119, creatinine 2.5, glucose 114, calcium 10.1; hematocrit 26.6, white count 6.7, platelet count 198, differential of 71 neutrophils, 2 bands, 19 lymphs, 6 monos, 2 eos; iron 274, tibc 439, b12 930, folate 11.3; inr 3.4; albumin 3.2. urinalysis 1.015, nitrite positive, protein 100, few white blood cells; urine culture on demonstrated citrobacter greater than 100,000 colonies sensitive to ceftriaxone; blood cultures on without growth. echocardiogram in showed normal left ventricle, normal right ventricle, ejection fraction 60%, + mitral regurgitation, 3+ tricuspid regurgitation, moderate pulmonary artery hypertension. echocardiogram in showed left atrial enlargement, trace mitral regurgitation, + tricuspid regurgitation, moderate pulmonary hypertension, increased right ventricular size, increased left ventricular size, ejection fraction 40%. hospital course: the patient is a 76-year-old female with multiple medical problems who was transferred from an outside hospital for further management of acute on chronic renal failure, congestive heart failure, and mental status changes. 1. cardiovascular: the patient was known to have a history of coronary artery disease and known congestive heart failure; however, the patient had never undergone a catheterization. echocardiogram obtained at the outside hospital in showed a decrease ejection fraction compared to her echocardiogram at our facility in . on original presentation to the outside hospital, the patient was thought to be in congestive heart failure and underwent significant diuresis with perhaps some component of overdiuresis. at the time of discharge to , the patient was felt to be rather dry, and therefore her lasix dose was held, and she was given a gentle fluid challenge of 500 cc. the patient responded to this with an increase in her urine output and improvement in her creatinine. a chest x-ray obtained at the time of discharge did not demonstrate any signs of heart failure, and urine electrolytes checked at the time of admission also suggested that the patient was likely dry. the patient was continued on her imdur, and a daily aspirin was added to her regimen given the likelihood of coronary artery disease. given that the patient had not tolerated reinitiation of her ace inhibitor at the outside hospital, this medication was also initially held. the patient was found to be in atrial fibrillation which is a chronic arrhythmia for her. she was therefore continued on her coumadin once her inr had fallen to appropriate levels. over the next few days, it was felt that the patient was likely peripherally but centrally volume overloaded. an attempt was made to provide the patient with enough fluid to adequately perfuse her kidneys and therefore correct her prerenal azotemia and yet not overload her poorly functioning hear to worsen her congestive heart failure. therefore over the next few hospital days, the patient was treated with a low dose of lasix, and her p.o. intake was encouraged. on the morning of , the patient was noted to have an acute episode of shortness of breath with a desaturation to the upper 80s on her 3 l nasal cannula. the patient was felt to suffer from diastolic cardiac dysfunction leading to flash pulmonary edema in the setting of fluid from a past red blood cell infusion. the patient was treated with lasix, nitropaste, and lopressor iv to treat her tachycardia. in addition, it was felt important to restart the patient's ace inhibitor in an effort to improve her renal perfusion. an echocardiogram was repeated which demonstrated a dilated left and right atrium, symmetric left ventricular hypertrophy, + mitral regurgitation, 3+ tricuspid regurgitation, and new left ventricular and right ventricular systolic dysfunction, with a small pericardial effusion, and an ejection fraction of 40-45%. given the patient's evidence of systolic dysfunction, her crackles on examination, and increased oxygen requirement, she was treated with low doses of lasix, and her ace and imdur were continued. over the next few hospital days, the balance was obtained between lasix iv and fluids in an effort to balance the patient's fluid status; however, on , the patient had significant abdominal pain with a fairly benign physical examination. it was thought that the patient was likely experiencing mesenteric ischemia, and an effort was made to obtain an abdominal ct scan in order to verify this possibility; however, in the setting of her rising creatinine, the patient was pretreated with fluid hydration and mucomyst prior to obtaining the ct scan. in the setting of this fluid therapy, the patient developed increasing shortness of breath, low oxygen saturations, and increasing acidosis. at the same time, the patient was also being treated with narcotic medication including three doses of oxycodone 5 mg p.o. in an effort to provide pain control for the patient's sacral decubitus ulcer. in the setting of fluid hydration and narcotic use, the patient had an acute episode of hypocarbic respiratory distress and was subsequently transferred to the micu. over the next four days in the micu, the patient was gently diuresed to treat her pulmonary edema and was placed on a narcan drip requiring three days of continuous narcan therapy for reversal of her narcotic induced mental status changes and decreased respiratory drive. while in the micu a renal consult was obtained who suggested that given the patient's poor cardiac function, she could not maintain her baseline creatinine of 1.4, as well as clear lungs and recommended tolerating a higher creatinine in order to keep her lungs dry. it was also suggested that the patient's ace inhibitor be discontinued and not restarted given that she had demonstrated multiple times in the past the inability to tolerate the ace based on increasing creatinine. while in the micu, the patient's cardiovascular status improved. she maintained a systolic blood pressure of approximately 130 to 140 and tolerated aggressive diuresis of approximately 1 l/day. on transfer back to the floor, the patient was felt to be euvolemic and was continued on her imdur, metoprolol 12.5 b.i.d. which was started for presumed diastolic dysfunction, nitro transdermal patch of 0.2 mg/hr, hydralazine 10 mg q.i.d., and a daily lasix dose of 20 mg p.o. per day. it was clear that part of the patient's problem resulting in transfer to the micu were secondary to narcotic overdose and subsequent hypercarbic respiratory distress; however, given the increased lactate, significant abdominal pain, and history of severe vascular disorder, it was felt likely that the patient may have experienced an intermittent mesenteric ischemia which may have also precipitated her respiratory distress. however, the patient's abdominal pain resolved in the micu, and this was never further evaluated. on transfer back to the floor, a cardiology consult was obtained in order to request aid in balancing the patient's congestive heart failure and poor cardiac function with her acute renal failure. cardiology also suggested that the patient's fluid status had been difficult to ascertain and manage over the past several weeks. they recommended obtaining a stress exam with a persantine thallium in order to assess for coronary ischemia which may be able to be reversed through catheterization. they also recommended titrating up her hydralazine and nitrates as tolerated. a persantine thallium was therefore obtained which demonstrated a moderately reversible defect in the inferior wall, an ejection fraction of 42%, significantly enlarged right ventricle, and global hypokinesis. review of the stress thallium with cards in the setting of the patient's overall functional status and chronic illness, it was felt that she would not likely benefit from a cardiac catheterization, and the best course of action was to resume medical management of the patient's coronary artery disease. over the next five or six hospital days, the patient was treated with cardiac medications including imdur, atenolol, hydralazine as tolerated, as well as continuing her nitro patch and continuing on a daily lasix dose of 20 mg p.o. q.d. the patient maintained systolic blood pressures in the 120s and demonstrated adequate urine output during this period; following placement of a peg tube on , the patient demonstrated an acute episode of respiratory distress and hypoxia. this responded to intravenous lasix, as well as 50-100% non-rebreather. by the morning, the patient's respiratory distress had significantly improved, and it was felt this was most likely secondary to an aspiration event resulting in aspiration pneumonitis which has since resolved. in addition, the patient's hypotension during this episode responded well to fluids, and her blood pressure was back at baseline by the next morning. over the few days following, on , the patient was treated with her continued gentle diuresis of lasix 20 mg p.o. q.d.; however, on , the patient demonstrated a drop in her blood pressure to a systolic of the high 90s to low 100s accompanied by a decrease in her urinary output. reevaluation suggested that the patient was likely dry and had been overdiuresed at this point. she was therefore treated with gentle fluids including 1 u of packed red blood cells, as well as small boluses of 250 cc a piece. when these small boluses did not demonstrate a significant increase in the patient's blood pressure nor urinary output, she was then placed on maintenance fluids in addition to her tube feeds. the patient received approximately 1 l/day over the 28th and 29th. subsequently on the morning of 30th, the patient had an acute onset of shortness of breath with an acute desaturation to 84% on her usual 3 l oxygen. this was felt to be likely in the setting of fluid overload, and therefore, the patient's maintenance fluids were stopped. she was given lasix 40 mg iv with some increase in her urinary output. in addition, the patient was tachycardiac; however, given her continued low blood pressure at the upper 90s, it was not felt prudent to give lopressor to slow her rate. given that the patient looked so uncomfortable, she was given morphine 1 mg iv. over the next few hours, the patient's mental status decreased significantly as did her respiratory rate. a blood gas obtained a few hours after administration of the morphine demonstrated impending acidosis of 7.27, co2 58, and an o2 of 90. the patient was treated with 0.4 narcan with significant increase in her mental status and respiratory rate. therefore, the patient was placed on a narcan drip, and given persistent hypercarbia and acidosis, she was placed on bipap therapy and transferred to the micu. therefore in summary, the patient was thought to have coronary artery disease with significant systolic and diastolic function based on echocardiogram results. this was felt to be best managed medically with hydralazine, nitrates, and beta-blockers, and there was felt to be no benefit from a cardiac catheterization; however, the patient's fluid status proved to be difficult to control as the patient persistently vacillated between being too wet and too dry. the overall plan was to maintain the patient's blood pressure with a systolic of approximately 130 in order to obtain adequate renal perfusion but to also provide her the benefit of cardiac medications including beta-blocker therapy, hydralazine, and nitrates. finally the patient was started on digoxin q.o.d. in an effort to improve her systolic function and therefore improve her renal perfusion. 2. pulmonary: at the time of admission the patient's initial chest x-ray demonstrated left lower lobe consolidation versus atelectasis which had been present since her chest x-rays in . the patient had been treated with one week of rocephin therapy, and on transfer, was afebrile with a normal white blood cell count and no pulmonary symptoms. it was therefore felt prudent to discontinue her antibiotic therapy and follow her pulmonary exam clinically. she was also encouraged to use incentive spirometer as tolerated in an effort to improve her left lower lobe atelectasis. during the hospital stay, as detailed in the cardiovascular system, the patient vacillated between pulmonary edema and dry lungs. the patient demonstrated her best pulmonary function when treated with lasix on a daily basis despite a bump in her creatinine to a baseline of 2.0. over the first two hospital days, the patient was treated with gentle fluid therapy, and just prior to transfer to the micu, the patient demonstrated an acute desaturation, as well as hypercarbic respiratory failure in the setting of narcotic therapy. the patient was diuresed effectively while in the micu and then transferred back out to the floor and maintained on a daily dose of lasix for her congestive heart failure; however, over the next few days, it was felt that the patient was likely being overdiuresed, as her systolic pressure began to drop. her lasix and other cardiac medications were discontinued, and the patient was treated with fluids including small fluid boluses and packed red blood cells. however, once again in the setting of small amounts of fluid therapy, the patient demonstrated an acute onset of shortness of breath with flash pulmonary edema and was therefore treated with further diuresis, and in this instance, placed on bipap therapy and transferred to the micu. 3. infectious disease: the patient was noted to have a citrobacter urinary tract infection on presentation to the outside hospital and completed a 7-day course of rocephin therapy at that hospital. urinalysis and culture obtained at the time of transfer demonstrated a normal urinalysis with no growth in the culture, and therefore, her rocephin therapy was held. however a few days following admission, the patient began complaining of burning with urination, and urinalysis was repeated which demonstrated significant candidal growth. the patient was therefore treated with fluconazole therapy and peridium with resolution of her urinary tract infection symptoms. the patient had no further urinary tract symptoms until the 29th at which time she once again began complaining of burning with urination through the catheter. a urinalysis was resent which demonstrated significantly elevated white blood cell count, as well as nitrite positive and leukocyte esterase positive. the patient was therefore started on levaquin pending final results of the urine culture. the patient demonstrated no evidence of pulmonary infection on the multiple chest x-rays obtained during her hospitalization. the left lower lobe consolidation versus atelectasis was felt to most likely represent some kind of mass or atelectasis as apposed to an infectious infiltrate. the patient demonstrated diarrhea during her hospital stay, and a c-difficile toxin was found to be positive. therefore, the patient was treated with a 21-day course of flagyl while in the hospital. the patient had no further signs or symptoms of infection up until the time of her transfer to the micu. during the entire course, the patient remained afebrile with a normal white blood cell count. 4. renal: the patient demonstrated an elevated creatinine on admission to the outside hospital which increased further with diuresis at the outside hospital and improved somewhat with hydration therapy. the patient was also felt to have possibly developed an interstitial nephritis secondary to rocephin therapy, and this antibiotic was discontinued at the time of transfer. over the course of the hospital stay, the patient's creatinine was elevated to approximately 1.9 to 2.0 which was felt to be required in order to keep the patient's lungs dry enough to decrease her oxygen requirement; however, following the peg tube placement when the patient began to experience lower systolic blood pressures, it was felt that her renal perfusion had decreased, and her urinary output began to decrease as well. a renal consult was reobtained, and a urinalysis was sent with sediment consistent with interstitial nephritis despite the fact that the patient had not undergone any medication changes recently. it was recommended to start levaquin therapy for a urinary tract infection and to attempt to maintain her systolic blood pressure greater than 130 to improve renal perfusion. following the episode of acute shortness of breath and desaturation on , it was recommended to attempt diuresis, and some thought was given towards the possibility that dialysis may need to be an option in the future. therefore, it was determined to begin initiation of discussion of dialysis with the patient and her husband should this become an issue. at the time of transfer to the micu, the patient's creatinine had increased on a daily basis up to 3.8 with an increasing bun up to 128. 5. gastrointestinal: the patient had no complaints of abdominal pain or suggestion of pathology at the time of admission; however, her stool was sent for c-diff which was positive, and the patient was therefore treated with a 21-day course of flagyl; however, approximately four days into the hospital stay, the patient began complaining of significant abdominal distress; however, her abdominal exam remained benign. although the patient's stool remained guaiac negative, she did demonstrate significant diarrhea, and given her history of significant peripheral vascular disease, it was felt that the patient might be experiencing an intermittent mesenteric ischemia. an attempt was made to obtained a ct scan to verify this thought; however, in the setting of fluid therapy and narcotic therapy for pain management, the patient developed significant hypercarbic respiratory distress and was transferred to the micu with subsequent resolution of her gastrointestinal symptoms. during the remainder of the hospital course, the patient maintained excellent colostomy output with no complaints of abdominal pain and benign abdominal exams. on , a peg tube was placed without complications, and tube feeds were initiated. the patient had no further gastrointestinal issues leading up to her micu transfer. 6. hematologic: the patient had been on coumadin for her chronic atrial fibrillation; however, this had been held secondary to elevated inr at the outside hospital. once the patient's inr had fallen below 3, her coumadin was restarted, and an attempt was made to maintain her inr between 2 and 3 during the course of the hospital stay. the patient also demonstrated a low hematocrit at the time of admission, however, had normal iron studies, b12, and folate at the outside hospital. it was felt that the patient's anemia was most likely secondary to chronic illness, and she was continued on her epogen shots. the patient was transfused 1 u packed red blood cells on three different occasions during the hospital stay prior to her transfer to the micu. the patient's stool remained guaiac negative during the hospital stay. 7. fen: the patient was attempted on a p.o. diet with boost supplement at the time of admission; however following transfer to the micu, a swallow study was obtained which demonstrated that the patient was aspirating significantly. follow-up studies continued to demonstrate aspiration, and therefore a peg tube was placed on . the patient's electrolytes were checked on a daily basis and repleted as needed. the patient will likely need continuation of her tube feeds until she has attained adequate strength in oropharyngeal control in order to refrain from aspirating. 8. wound care: the patient demonstrated a stage 3 sacral decubitus wound at the time of admission which was followed by dr. in plastic surgery. a plastic consult was obtained at the time of admission who suggested that the patient's wound was healing appropriately with good granulation tissue and that no surgical intervention would be necessary at this time. the patient's wound was packed with duoderm gel and normal saline gauze b.i.d. throughout the course of the hospital stay and continued to demonstrate good granulation tissue without evidence of infection. 9. neurological: the patient demonstrated a fluctuating mental status over the course of the hospital stay which was significantly altered by the administration of any narcotics or benzodiazepine therapy. approximately four days into the hospital stay, the patient was treated with oxycodone 5 mg p.o. q.6 hours times three doses in an attempt to help her gain control over her significant abdominal pain and sacral decubitus pain. following this, the patient developed an acute respiratory distress with hypercarbia and was transferred to the micu and placed on a narcan drip. following this episode, the patient was not administered any further narcotics until her acute episode of shortness of breath with desaturations . at this time 1 mg morphine was provided to the patient in an effort to provide comfort, and she subsequently developed, once again, a hypercarbic respiratory distress and increasing acidosis. she was therefore placed on a narcan drip with great improvement in her mental status. in addition in retrospect, it was found that the patient's mental status was most clear when her lungs were dry and her oxygen saturations were high. , m.d. dictated by: medquist36 procedure: enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrojejunostomy diagnoses: pneumonia, organism unspecified urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified acute respiratory failure intestinal infection due to clostridium difficile hyperosmolality and/or hypernatremia 

Answer: The patient is high likely exposed to