Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia major surgical or invasive procedure: tracheostomy percutaneous endogastric tube intubation and extubation history of present illness: 70 y/o f with pmhx of severe copd and recent nstemi who was transferred in from rehab due to increased sob over the prior 3-4 days. this am, she was noted to have low sats in 70% which did not respond to nebs. her sats came up with high flow o2 in the ems. pt denied any cough, increased sputum, chest pain or pedal edema. she was notably wheezey on presentation and was initially treated as copd exacerbation. . in the ed, initial vs were: t 97.6 bp 146/70 hr 147 rr 20 sats 96% on ra. patient was given solumedrol 125mg, nebs & levofloxacin for lll infiltrate seen on cxr. on re-evaluation, pt was lethargic and desatting into the 70s. pt was intubated for respiratory failure and received ceftriaxone and vancomycin for presumed pna. pt was noted to have sbps in 80s peri-intubation and received a total of 6l of ivf. pt had a tmax of 103.8 in the ed, though lactate was normal at 1.7. pt was transferred to the icu on versed/fentanyl and dopamine to maintain sbps. . on arrival, pt was intubated and sedated though following commands. she reported some chest pain but was otherwise comfortable and sating 100% on the vent. past medical history: copd htn carotid stenosis pvd: aortoileac disease, followed by dr. osteoporosis cad s/p nstemi depression/anxiety social history: previously lived alone, works in publishing, etoh: one drink days per week, nonsmoker, quit smoking 15 yrs ago, smoked for about 30 years. former vp of celtics business operations. niece involved in care. family history: non contributory physical exam: vitals: t: 97.5 bp: 103/51 p: 99 r: 14 sats 100% on ac 500/5/14/100% general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular 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: 10:00am blood wbc-17.0* rbc-3.66* hgb-11.2* hct-34.8* mcv-95 mch-30.5 mchc-32.1 rdw-15.4 plt ct-425# 03:20am blood wbc-15.8* rbc-2.64* hgb-8.0* hct-25.1* mcv-95 mch-30.4 mchc-31.9 rdw-15.5 plt ct-288 03:59am blood wbc-24.4* rbc-2.82* hgb-8.6* hct-26.7* mcv-95 mch-30.6 mchc-32.3 rdw-15.6* plt ct-306 03:01am blood wbc-16.7* rbc-2.81* hgb-8.5* hct-26.2* mcv-93 mch-30.2 mchc-32.4 rdw-16.0* plt ct-251 03:16am blood wbc-41.1*# rbc-3.03* hgb-9.2* hct-28.0* mcv-92 mch-30.5 mchc-33.0 rdw-15.5 plt ct-349 03:10am blood wbc-25.0* rbc-2.82* hgb-8.4* hct-25.6* mcv-91 mch-29.9 mchc-33.0 rdw-15.3 plt ct-301 03:56am blood wbc-15.9* rbc-3.29* hgb-9.6* hct-30.0* mcv-91 mch-29.2 mchc-32.0 rdw-15.1 plt ct-391 03:05am blood wbc-15.3* rbc-3.43* hgb-10.3* hct-31.1* mcv-91 mch-30.0 mchc-33.1 rdw-15.1 plt ct-422 10:00am blood pt-13.6* ptt-24.4 inr(pt)-1.2* 03:20am blood pt-14.8* ptt-30.2 inr(pt)-1.3* 04:31am blood pt-13.1 ptt-38.5* inr(pt)-1.1 03:05am blood pt-13.8* ptt-35.1* inr(pt)-1.2* 10:00am blood glucose-188* urean-16 creat-0.5 na-138 k-4.5 cl-93* hco3-37* angap-13 03:59am blood glucose-121* urean-16 creat-1.0 na-140 k-4.0 cl-108 hco3-26 angap-10 02:05am blood glucose-107* urean-30* creat-1.2* na-146* k-3.1* cl-106 hco3-32 angap-11 03:54am blood glucose-90 urean-14 creat-0.5 na-138 k-3.9 cl-102 hco3-32 angap-8 03:05am blood glucose-95 urean-15 creat-0.5 na-139 k-3.7 cl-92* hco3-40* angap-11 04:47pm blood alt-71* ast-113* ld(ldh)-294* ck(cpk)-27 alkphos-102 totbili-0.4 10:00am blood ctropnt-0.01 04:47pm blood ck-mb-notdone ctropnt-<0.01 03:20am blood ck-mb-notdone ctropnt-<0.01 ----------------- discharge labs: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 03:05am 15.3* 3.43* 10.3* 31.1* 91 30.0 33.1 15.1 422 . inr 1.2 renal & glucose glucose urean creat na k cl hco3 angap 03:05am 95 15 0.5 139 3.7 92* 40* 11 . cxr: impression: focal consolidation in the left peripheral mid lung superimposed on changes of emphysema. this is consistent with pneumonia. . cxr: impression: ap chest compared to 7:12 p.m. nasogastric tube ends in the upper portion of a nondistended stomach. although the tip of the et tube is less than 2 cm from the carina and the chin is down, this is only 1 cm below optimal placement. right pic line ends at the junction of the brachiocephalic veins. residual of pneumonia in the left mid lung has been stable for several days. small bilateral pleural effusion has increased slightly since earlier in the day, and there is pulmonary vascular redistribution but no edema. heart size is normal. thoracic configuration indicates copd. . a region of scar-like opacity in the axillary portion of the right mid lung is more radiodense than it was earlier in and largely new since . this could also be post-inflammatory, but is concerning for possible malignancy. followup is advised clinically indicated, with chest ct, which can be compared to the ctpa on . dr. and i discussed these findings at the time of dictation. . impression: little overall change. . cxr: : findings: in comparison with the study of , the tracheostomy tube and picc line remain in place. hyperinflation of the lungs is again seen consistent with chronic pulmonary disease. extensive areas of scarring persist. more focal opacifications laterally in the mid lung zone on both the right and left are again seen. no evidence of pneumothorax. . echo: : conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , regional and global left ventricular systolic function are improved. the estimated pulmonary artery systolic pressure is now slightly higher. based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . ecg: sinus rhythm. left bundle-branch block with secondary repolarization abnormaliites. compared to the previous tracing of no diagnostic change. . microbiology: blood culture, now growth from and ucx: now growth from ucx: + yeast urine legionella ag: negative sputum cx : gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): tiny pleomorphic gram negative coccobacilli. respiratory culture (final ): sparse growth oropharyngeal flora. haemophilus influenzae, beta-lactamase negative. moderate growth. beta-lactamse negative: presumptively sensitive to ampicillin. confirmation should be requested in cases of treatment failure in life-threatening infections.. . sputum cx: 9:32 am mini-bal **final report ** gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | amikacin-------------- 8 s cefepime-------------- 16 i ceftazidime----------- 8 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem------------- 1 s piperacillin---------- 32 s piperacillin/tazo----- 32 s tobramycin------------ =>16 r . c. diff: toxin negative ------ , pt had sputum performed at : 2 different pseudomonas 1st strain pan resistant except amikacin & imipenem 2nd strain sensitive to zosyn/ceftaz/cefepime brief hospital course: 70 y/o f with severe copd who presents with hypoxia and respiratory failure, now intubated. . # resp failure: patient was intubated on presentation for severe respiratory distress. was empirically treated for copd exacerbation and given cxr findings was treated for pneumonia as well. sputum cultures subsequently grew haemophilus which was treated with a course of ceftriaxone. patient had difficulty weaning from the vent but was given a trial of extubation after several days of slow improvement. she managed approximately 12-18 hours extubated before she needed to be reintubated for respiratory distress. following her second intubation patient developed elevated wbc count to 40. was pan cultured and empirically treated for c. diff infection. data subsequently revealed a gnr in the sputum and diagnosis of vap was made. she was started on doripenem given a history of meropenem resistant isolates in the past. sensitivities on gnr subsequently revealed a meropenem gnr and after discussion it was determined that patient could be treated with a course of meropenem. lastly, patient was more than 20l positive on day prior to discharge, but diuresing well. - meropenem to complete on - continue to diurese as tolerated with goal 2l negative per day to facilitate weaning from the trach. - if patient not responding clinically to meropenem may require doripenem for coverage. - at time of discharge, tolerating trach collar w/o difficulty. - tapered steroids down to 10mg prednisone which was pre-admission dose - continue pcp prophylaxis given steroids . # hypotension: likely septic physiology on admission. treated with stress dose steroids given h/o long standing steroid use, and tapered back to preadmission baseline prior to discharge. subsequently started on anti-hypertensive regimen of lisinopril and diltiazem. . # cad/chest pain: pt with recent nstemi who presented with hypoxia and was denying cp in ed. ekgs with sinus tach in 140s, lbbb and non-specific changes from baseline. patient did not rule in during hospital stay. echocardiogram results did no demonstrate significant cardiac pathology. was restarted on asa, lipitor, ace-i. transiently with atrial fibrillation. not restarted on anti-coagulation on discharge given acute medical issues and that episode of a. fib was in setting of substantial acute lung pathology. would reassess need for anticoagulation given episode of a. fib as an outpatient. continue diltiazem. - uptitirate lisinopril as tolerated - recommend repeating electrolytes while actively diuresing patient with lasix and uptitrating lisinopril would follow creatinine regularly. . # hct drop: thought to be dilutional. no major bleeding source identified. patient received 2 units prbc's during her hospital stay and was trace guaiac positive. - consider outpatient colonoscopy when able. . # anxiety: started on clonazepam prior to discharge for treatment of anxiety. to use ativan prn. . # ?lung mass: irregular opacity in r-mid lung noted on chest films that was new from . recommend obtaining a ct scan of her chest for further evaluation. this was not done during this hospitalization given her other acute medical conditions. . # fen: peg placed prior to discharge and started on tube feeds. . # prophylaxis: heparin sc tid, bowel regimen, ppi . # access: picc line placed . # code: full . # disposition: to rehab for trach care. . # communication: niece, patient, (pa) who has been caring for ms. in her current rehab setting. (her phone number is ). the patient's niece became involved and visited often. we had several end of life discussions with the patient and she agreed to trach and full code while hospitalized. medications on admission: aspirin 81mg atorvastatin 40mg xopenex prn tiotropium daily advair alendronate 70mg weekly colace senna prn mucomyst inhaled vitamin b12 diltiazem 120mg daily prednisone 10mg daily ativan prn robitussin prn discharge medications: 1. aspirin 325 mg tablet : one (1) tablet po daily (daily). 2. atorvastatin 40 mg tablet : one (1) tablet po daily (daily). 3. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 4. levalbuterol hcl 0.63 mg/3 ml solution for nebulization : 0.63mg/3ml ml inhalation q4hr (). 5. ipratropium bromide 17 mcg/actuation aerosol : two (2) puff inhalation q6h (every 6 hours). 6. fentanyl 25 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 7. heparin (porcine) 5,000 unit/ml solution : one (1) injection (2 times a day). 8. zolpidem 5 mg tablet : one (1) tablet po hs (at bedtime) as needed. 9. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day). 10. cholecalciferol (vitamin d3) 400 unit tablet : two (2) tablet po daily (daily). 11. citalopram 20 mg tablet : 0.5 tablet po daily (daily). 12. clonazepam 0.5 mg tablet : one (1) tablet po tid (3 times a day). 13. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr once a day. 14. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 15. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 16. prednisone 10 mg tablet : one (1) tablet po daily (). 17. lisinopril 5 mg tablet : one (1) tablet po daily (daily). 18. ondansetron hcl (pf) 4 mg/2 ml solution : one (1) injection injection q8h (every 8 hours) as needed for nausea. 19. trimethoprim-sulfamethoxazole 80-400 mg tablet : one (1) tablet po daily (daily). 20. diltiazem hcl 30 mg tablet : one (1) tablet po qid (4 times a day). 21. insulin lispro 100 unit/ml solution : as per sliding scale as per sliding scale subcutaneous asdir (as directed). discharge disposition: extended care facility: for the aged - discharge diagnosis: community acquired pneumonia ventilator associate pneumonia respiratory failure status post tracheostomy placement chronic obstructive pulmonary disease chronic steroid use osteoporosis depression/anxiety discharge condition: stable. afebrile. patient is doing daytime trach mask, interchanged with pressure support mechanical ventilation at night. discharge instructions: you were admitted with an pneumonia. for this you were intubated. you had difficulty weaning from the ventilator, but were given a trial of extubation. you had difficulty breathing on your own during this trial and were reintubated to protect you. as a result, you had a tracehostomy placed to allow you to wean from the vent slowly over time. you were treated for two pneumonias during your hospital stay, and have been steadily improving prior to discharge. followup instructions: please f/u with doctors at rehab. provider: , m.d. phone: date/time: 8:00 provider: , m.d. date/time: 9:50 md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus diagnoses: pneumonia, organism unspecified urinary tract infection, site not specified obstructive chronic bronchitis with (acute) exacerbation dysthymic disorder acute respiratory failure osteoporosis, unspecified hypovolemia ventilator associated pneumonia subendocardial infarction, subsequent episode of care pseudomonas infection in conditions classified elsewhere and of unspecified site chronic pulmonary heart disease, unspecified 

Answer: The patient is high likely exposed to