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: no known allergies / adverse drug reactions attending: chief complaint: respiratory distress major surgical or invasive procedure: subclavian line placement and removal picc placement history of present illness: 53 yo f with tracheomalacia s/p tracheostomy, mental retardation, dm, htn, peripheral vascular disease, recently discharged from after an episode of hypotension thought to be viral gastroenteritis now presents from living facility after being found cyanotic with o2sat in the low 80s%, somnolent, febrile to 101 and hyperglycemic to 283 per ems. she was suctioned by ems (thick secretion) and received tylenol and ativan. . in the ed, initial vs were: t 102.4, p 128, bp 111/66, rr 32, o2sat 100% on 15l face mask. per ed sign-out, patient was noted to have right sied and left sided infiltrate, arf, lactate up to 4.5, + ua. cultures were sent from the blood and urine. she was given cefepime, vancomycin, and ciprofloaxin in addition to 650 mg tylenol and 600 mg ibuprofen. she was also noted to have transient hypotension 76/50 although unclear if it is an accurate read given that her sbp improved to the 110s with minimal ivf. she received 2l of ivf. upon transfer, her vs t103.8f, bp 132/57, hr 115 o2sat 97% on 50%. she has an 18 g iv, and is a difficult stick. per report, patient is usually on trach mask and hcp is . per the facility, patient was at her usual state of health this morning with borderline temperature of about 100. when they saw her again in the afternoon, she was noted to be in respiratory distress, fever, and agitation. therefore, she received tylenol and ativan. of note, her warfarin was stopped about 3 days prior to admission because of some bleeding around the trach site and elevated inr up to at that time, it was decided that she should not be on anticoagulation anymore. . upon reviewing record from . patient was seen on for sob and blood with her cough in the setting of supratherapeutic inr for which it was held. according to that discharge instruction, patient was recommended to restart warfarin once inr improves. . on the floor, patient appears lethargic. opens eyes to voice. denies pain. on 3rd l of fluid. past medical history: mental retardation tracheomalacia s/p tracheostomy h/o aspiration pneumonia diabetes mellitus h/o c. difficile infection, glaucoma hypertension hld osteoarthritis depression/anxiety, constipation psychosis . past surgical history: tracheostomy and peg , r total knee replacement r hip replacement right common iliac artery stent placement and right external iliac recanalization with stent placement x2. social history: lives at nursing home in , ma. father and brother are -guardians family history: unable to obtain physical exam: admission exam general: lethargic, opens eyes to voice, followed simple command ("open your mouth") heent: sclera anicteric, mucous membrane dry neck: supple, jvp difficult to appreciate lungs: anterior lung field, diffused expiratory wheeze, diminished air movement, no rhonchi or crackles. cv: tachycardic, difficult to appreciate any murmur, rub, or gallops abdomen: large well healed scar in the ruq. soft, non-tender, non-distended, obese, bowel sounds present, no guarding, no organomegaly. g-tube in place gu: foley, clear yellow urine ext: warm. distal pulses (dp and pt) non-palpable but dopplarable. + dry gangrenous change in all digits of the right foot. exam on discharge t: 98.8 (axillary), hr 77, bp 107/50, o2sat 96% on fio2 of 40% general: alert, awake, answers questions with yes/no answers by nodding and shaking head heent: sclera anicteric, mucous membrane moist, minimal crusting in the eye neck: supple, jvp difficult to appreciate lungs: anterior lung field, diffused poly-phonic expiratory wheeze, no crackles. cv: regular rate and rhythm, difficult to appreciate any murmur, rub, or gallops abdomen: large well healed scar in the ruq. soft, non-tender, non-distended, obese, bowel sounds present, no guarding, no organomegaly. g-tube in place gu: foley, clear yellow urine ext: warm. distal pulses (dp and pt) non-palpable but dopplarable. + dry gangrenous change in all digits of the right foot, worse on the little toe. pertinent results: 1. labs on admission: 06:00pm blood wbc-25.8*# rbc-3.56* hgb-10.9* hct-32.5* mcv-91 mch-30.7 mchc-33.7 rdw-17.1* plt ct-426 06:00pm blood pt-12.1 ptt-19.5* inr(pt)-1.0 06:00pm blood glucose-312* urean-36* creat-1.5* na-133 k-4.7 cl-83* hco3-36* angap-19 06:00pm blood alt-6 ast-21 alkphos-80 totbili-0.5 06:00pm blood albumin-3.5 calcium-9.6 phos-3.3 mg-2.3 . 2. labs on discarge: - ammonia 80 - lactate 1.5 - na 143, k 4.3, cl 98, bicarb 38, bun 32, creatinine 0.9, glucose 162, calcium 9.6, magnesium 2.6, phosphate 2.4 - wbc 9.3, hemoglobin 8.9, hematocrit 27, plt 307 - tsh 9.5, total t4 3.9, free t4 0.60 . 3. imaging/diagnostics: cxr impression: 1. low lung volumes. 2. prominence and indistinctness of the hila may be due to pulmonary vascular engorgement. bibasilar opacities may relate to fluid overload, although infection is not excluded. . echo conclusions the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. the pulmonary artery systolic pressure is unable to be determined. there is no pericardial effusion. impression: preserved global biventricular systolic function. no pathologic valvular regurgitation or stenosis. compared with the prior report (images unable to be reviewed) of , the findings are similar. . cta impression: 1. technically limited study with no evidence of a central (main, lobar or segmental) pulmonary embolism. 2. diffuse, severe tracheomalacia below the level of the tracheostomy tube with associated moderately severe air trapping in both lungs. 3. small bilateral pleural effusions, bilateral lower lobe atelectasis and consolidation in the right lower lobe. . cxr impression: 1. left pic catheter tip projects over mid to low svc. no pneumothorax. 2. unchanged right pleural effusion. 3. bibasilar opacities, likely atelectasis, however, superimposed infection cannot be excluded. 4. persistent pulmonary vascular congestion. microbiology: - blood culture, routine (final ): escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s anaerobic bottle gram stain (final ): gram negative rod(s). reported to and read back by (4i) @ 9:14 am . aerobic bottle gram stain (final ): gram negative rod(s) - urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s 11:59 am sputum gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing confirmed by . pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing confirmed by . staph aureus coag +. sparse growth. 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 _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | staph aureus coag + | | | cefepime-------------- 4 s 2 s ceftazidime----------- 4 s 4 s ciprofloxacin--------- 2 i 2 i clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=1 s <=1 s <=0.5 s levofloxacin---------- =>8 r meropenem------------- 2 s 4 s oxacillin------------- =>4 r piperacillin/tazo----- 16 s 16 s rifampin-------------- <=0.5 s tetracycline---------- 2 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s last cultures: pending blood cultures- no growth to date c. diff negative urine culture negative brief hospital course: ms. is a 53 year old woman with tracheomalacia s/p tracheostomy, mental retardation, dm, htn, peripheral vascular disease, and other medical issues who presented from her living facility with hypoxia and tachycardia. . #. hypoxic respiratory distress. when patient initially presented, there was concern of a pneumonia vs. pulmonary edema. she was initially treated for possible hospital acquired pneumonia and an aspiration pneumonia. initial treatment was with vancomycin and zosyn. this was transitioned to cefepime, vancomycin, cipro, and flagyl. her sputum grew out pseudomonas and mrsa, though it was unclear whether this data reflected chronic colonization versus pathogenic infection. treatment for pna was continued based on ct evidence of rll consolidation. she completed 8 days of vancomycin but then had a borderline fever, so it was restarted. he will continue a 14 day course of vancomycin and cefepime to co-treat pseuodmonas pneumonia and e coli urosepsis, to be completed on . with antibiotics and nebulizer treatments, her oxygen was weaned to baseline 35-40% via trach mask. trach exchange and pmv can be done in the outpatient setting. . #. urinary tract infection/urosepsis. she was found to have pan-sensitive e.coli in her urine as well as in her blood. she was started on antibiotics and will complete a 14 day course of cefepime on . . #. sepsis. on initial presentation patient had fever, leukocytosis, and tachycardia. her lactate was 4.5. the infection was thought to be a combination of a urinary and pulmonary source. her lactates trended down. as above, she will finish 14 days cefepime for e coli urosepsis/pseudomonal pneumonia and total of 14 days of vancomycin for possible mrsa pneumonia. she was aggressively fluid resuscitated initially . # altered mental status: she had a waxing and level of interaction, at times following commands and answering questions, and at times indifferent to them. this pattern was felt to be due to hypoactive delirium in the setting of acute infection which improved by the time of discharge to her baseline. per her pcp, is able to answer questions, read and write normally. by the time of discharge, patient was alert and was able to answer yes-no questions by nodding and shaking her head appropriately. she was also able to follow commands. she does exhibit waxing-wanning mental status, particularly after morning doses of seroquel. it will be importnt for the rehab facility to reassess her mental status as she continue to improve from her recent infection to determine if dosage of her seroquel should be lowered. #. peripheral vascular disease. ms. has a history of pvd. she is s/p stents in the right iliac. previously she had been on warfarin. her last discharge summary instructs her to continue this medication. however, her recent lists did not include this. we contact her living facility who stated it had been stopped for unclear reasons. in addition, on warfarin she had a subtherapeutic inr. vascular was contact. they initially recommended starting heparin. however her primary vascular surgeon stated that aspirin was sufficient. per her vascular surgeon, her dry gangrenous changes in the right toes have been stable for month. . #. acute renal failure. on presentation her creatinine was up to 1.5 from baseline 0.7. this was thought likely to sepsis. she rapidly improved with fluids suggesting pre-renal azotemia. . #. contraction alkalosis. elevated bicarb toward the end of her stay in the icu. this is the result of aggressive diuresis for her respiratory status. the plan is to restart home dose lasix 20 mg po daily once her bicarb return to less than 34. . #. dm. on 54 units of lantus qhs according to med list from the d/c summary. given that she will be npo, will decrease her insulin dosage for now . #. psychosis. did not have symptoms while on home seroquel 250 mg tid and valproic acid 500 mg qam and 750 mg qpm. valproic acid level was not hight but has a mildly elevated ammonia level. would recommend repeating the level again once her infection is resolved. if still elevated, consider lactulose. . #. subclinical hypothyroidism. tsh was found to be mildly elevated at 9.5 with free t4 at 0.6. given in acute setting, she should get repeat tsh and free t4 checked again once she becomes clinically more stable to determine if replacement therapy will be needed. . #. medications. lopressor 75 mg tid was held initially given sepsis. it was restarted gradually, however, because of transient hypotension with sbp in the 80s-90s, metoprolol was stopped. amlodipine was held given initial sepsis, and it was not restarted for the same reason. transitional care: called dr. at prior to transfer on . outpatient follow up with her primary care provider outpatient follow up with her interventional pulmonologist outpatient follow up with her vascular surgeon follow up of her electroltyes. once bicarb is < 34, can restart lasix 20 mg po monitor blood pressure and heart rate. once returning to baseline, can restart home dose metoprolol and amlodipine check vancomycin level on check chem 10 on repeat tsh and free t4 once infection is cleared to determine if she needs to be on replacement therapy repeat ammonia level once her infection is resolved. medications on admission: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. quetiapine 250 mg tablet sig: one (1) tablet po tid (3 times a day). 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 5. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: seven y (750) mg po qpm (once a day (in the evening)). 6. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: five hundred (500) mg po qam (once a day (in the morning)). 7. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1) application ophthalmic qid (4 times a day) for 1 weeks. 8. amlodipine 2.5 mg tablet sig: three (3) tablet po daily (daily). 9. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 10. fenofibrate 54 mg tablet sig: one (1) tablet po once a day. 11. medication administration all medications should be given through g-tube 12. calcium carbonate 500 mg/5 ml (1,250 mg/5 ml) suspension sig: five (5) ml po daily (daily). 13. lantus 100 unit/ml solution sig: fifty four (54) u subcutaneous at bedtime. 14. insulin regular human 100 unit/ml solution sig: one (1) injection injection four times a day: per humalog insulin sliding scale. 15. lactobacillus acidophilus 100 million cell capsule sig: one (1) capsule po once a day. 16. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 17. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm.--> per facility, this was discontinued 3 days prior to admission. discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. therapeutic multivitamin tablet sig: one (1) tablet po daily (daily). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po once a day. 4. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: fifteen (15) ml po qpm (once a day (in the evening)): total of 750 mg. 5. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: five (5) ml po qam (once a day (in the morning)): total of 250 mg. 6. quetiapine 50 mg tablet sig: five (5) tablet po three times a day: please crush and give through peg tube. . 7. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1) application ophthalmic four times a day. 8. fenofibrate 54 mg tablet sig: one (1) tablet po once a day. 9. calcium carbonate 500 mg/5 ml (1,250 mg/5 ml) suspension sig: five (5) ml po once a day. 10. lantus 100 unit/ml solution sig: fifty four (54) units subcutaneous at bedtime. 11. insulin regular human 100 unit/ml solution sig: one (1) injection injection four times a day: per sliding scale. 12. lactobacillus acidophilus 100 million cell capsule sig: one (1) capsule po once a day. 13. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 6 days: to be completed on . disp:*12 gram* refills:*0* 14. cefepime 2 gram recon soln sig: two (2) grams injection q12h (every 12 hours) for 6 days: to be completed on . 15. outpatient lab work please check chemistry 10 (sodium, potassium, chloride, bicarbonate, bun, creatinine, calcium, phosphate, and magensium) on . please fax the result the covering physician at . 16. outpatient lab work please check vancomycin trough 1 hour prior to the schedule dose on . please fax the result the covering physician at . discharge disposition: extended care facility: northeast - discharge diagnosis: primary diagnoses: - e. coli urosepsis - respiratory distress from pseudomonal and mrsa pneumonia - delirium, resolved. secondary diagnoses: - tracheomalacia - peripheral vascular disease - diabetes mellitus - subclinical hypothyroidism discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mrs. , you were admitted to for treatment of shortness of breath and a fast heart rate, which were likely due to a combination of a pneumonia and urinary tract infection that spread to your blood. you were treated with very strong antibiotics and your breathing and blood pressure eventually improved. you had some confusion as a result of this infection, although this symptom also improved with treatment. you will need few more days of antibiotics to help fight these infections to be completed on . your vascular surgeon was contact about the need for warfarin given your peripheral vascular disease. it is decided that aspirin alone will be sufficient for now. your pulmonologist (lung doctor) was contact to inform your admission to the hospital. you will need to follow up with him about further management of your trach. you will need to have your antibiotics level checked tomorrow on . you will also need to have your electrolytes checked on . your doctor at the facility will help you to make adjustments in your medications as needed. the following changes were made to your medications: 1. start cefepime 2 grams every 12 hours for 6 days, ending on 2. start vancomycin 1 g every 12 hours for 6 days, ending on 3. discontinue metoprolol. your doctor will help you to decide when to restart this medication. 4. discontinue amlodipine. your doctor will help you to decide when to restart this medication. 5. discontinue furosemide. your doctor will help you to decide when you can restart this medication. followup instructions: please call your pcp, . , when you return from rehab to follow up on your hospitalization please call your interventional pulmonologist, dr. , to set up a follow up appointment. department: vascular surgery when: wednesday at 10:45 am with: , md building: lm bldg () campus: west best parking: garage procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances diagnoses: urinary tract infection, site not specified unspecified essential hypertension acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified acquired hypothyroidism peripheral vascular disease, unspecified sepsis dysthymic disorder other and unspecified hyperlipidemia acute and chronic respiratory failure pneumonia due to pseudomonas alkalosis septicemia due to escherichia coli [e. coli] knee joint replacement tachycardia, unspecified gastrostomy status other alteration of consciousness tracheostomy status hip joint replacement unspecified intellectual disabilities other diseases of trachea and bronchus unspecified psychosis methicillin resistant pneumonia due to staphylococcus aureus 

Answer: The patient is high likely exposed to