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: xanax attending: chief complaint: right lower extremity worsening heel ulcer major surgical or invasive procedure: : debridement of right heel skin and subcutaneous tissue down to bone. : right excisional debridement, partial calcanectomy right side. : debridement of skin and subcutaneous tissues right heel. : debridement of open wounds right side and right ischium measuring 12 x 12 cm on the right thigh, and 9 x 8 cm on the right ischium, and placement of vacuum-assisted closure dressing. history of present illness: ms. is a 60 year old woman who presents to the ed with wet gangrene of her right heel. she is s/p b/l femoral-popliteal bypasses and a tma of her left foot. her symptoms began 1 month ago when she noted redness of her right leg and foot. she treated this with some form of ointment after which she noted worsening drainage from her heel prompting her to be admitted to hospital. she was started on invanz, a picc line was placed on and she was transferred to a rehab facility. per the rehab records she initially was admitted with dry gangrene of the heel which has progressively worsened. she was evaluated by wound care nursing and a surgeon who felt inpatient admission and debridement would be needed and she was therefore transferred to for further care. she denies fevers and chills, but does report significant pain in her right foot. past medical history: pmh: diabetes, hypertension, obesity, smoking, anemia, cad, chf, gerd, hx of vre psh: - cabg x2 c/b sternal wound infections requiring multiple debridements and skin grafting ' - ventral hernia repair ' - l cfa-ak bpg c/b left groin mrsa infection - l tma - s/p orif l supracondylar femur fx on and revision - angioplasty of l bpg - r cfa-ak bpg w/ nrsv c/b groin infection w/ proteus, pseudomonas requiring debridement social history: former smoker 2ppd x 20 years, quit 25 years ago. denies alcohol or ivd use. lives with sister. family history: non-contributory physical exam: vital signs: temp: 97.4 rr: 20 pulse: 69 bp: 139/60 neuro/psych: oriented x3, affect normal, nad. neck: no masses, trachea midline, thyroid normal size, non-tender, no masses or nodules, no right carotid bruit, no left carotid bruit. nodes: no clavicular/cervical adenopathy, no inguinal adenopathy. skin: no atypical lesions. heart: regular rate and rhythm. lungs: clear, normal respiratory effort. gastrointestinal: non distended, abnormal: obese, large midline scar from hernia repair. extremities: abnormal: difficult groin exam given significant pannus. b/l venous stasis changes, l tma well healed. pulse exam (p=palpation, d=dopplerable, n=none) rue radial: p. lue radial: p. rle dp: p. pt: p. lle dp: p. pt: d. description of wound: large area of wet gangrene over right heel with surrounding erythema, unable to express puss. does not probe to bone. pertinent results: 09:17am blood wbc-11.3* rbc-2.84* hgb-8.0* hct-24.8* mcv-87 mch-28.2 mchc-32.2 rdw-17.6* plt ct-358 05:15pm blood glucose-190* urean-34* creat-1.2* na-138 k-4.5 cl-99 hco3-30 angap-14 06:00am blood glucose-94 urean-42* creat-2.2* na-138 k-4.0 cl-105 hco3-26 angap-11 04:29am blood glucose-115* urean-52* creat-3.7* na-135 k-3.7 cl-103 hco3-25 angap-11 04:40am blood glucose-80 urean-53* creat-4.2* na-134 k-3.5 cl-101 hco3-23 angap-14 03:30pm blood glucose-94 urean-55* creat-4.3* na-136 k-3.8 cl-102 hco3-24 angap-14 03:54am blood glucose-80 urean-56* creat-4.4* na-135 k-3.8 cl-102 hco3-25 angap-12 05:03pm blood glucose-136* urean-55* creat-4.2* na-134 k-3.9 cl-101 hco3-24 angap-13 04:10am blood glucose-95 urean-56* creat-4.2* na-136 k-3.6 cl-101 hco3-26 angap-13 05:57pm blood urean-55* creat-4.0* na-135 k-3.5 cl-99 hco3-25 angap-15 04:06am blood glucose-115* urean-53* creat-3.9* na-137 k-3.9 cl-101 hco3-26 angap-14 08:03pm blood urean-42* creat-2.8* na-131* k-3.9 cl-94* 05:10am blood glucose-121* urean-46* creat-2.1* na-133 k-4.2 cl-92* hco3-32 angap-13 05:37am blood glucose-107* urean-44* creat-1.9* na-135 k-4.1 cl-94* hco3-32 angap-13 02:54pm blood glucose-155* urean-42* creat-1.9* na-136 k-4.0 cl-96 hco3-31 angap-13 05:19am blood glucose-88 urean-43* creat-1.9* na-137 k-4.3 cl-95* hco3-34* angap-12 11:15pm blood glucose-135* urean-43* creat-1.9* na-135 k-4.2 cl-95* hco3-31 angap-13 09:17am blood glucose-134* urean-42* creat-1.8* na-137 k-4.4 cl-97 hco3-31 angap-13 05:10am blood tobra-3.3* 05:37am blood tobra-1.8* 09:17am blood tobra-0.8* . foot x rays: impression: diffuse soft tissue swelling without definite signs of soft tissue gas or foreign body. probable ulceration along the soft tissues at the heel without underlying signs of osteomyelitis. . 10:47 pm foot culture source: r heel. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 1+ (<1 per 1000x field): gram negative rod(s). wound culture (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. pseudomonas aeruginosa. heavy growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem------------- 2 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s time taken not noted log-in date/time: 9:27 am tissue right foot. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. tissue (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. pseudomonas aeruginosa. sparse growth. identification and sensitivities performed on culture # . anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. 2:55 pm tissue right heel. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): staph aureus coag +. 1 colony on 1 plate. 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. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s anaerobic culture (final ): no anaerobes isolated. 3:05 pm tissue right heel margin. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive cocci. in pairs. tissue (final ): staphylococcus, coagulase negative. isolated from broth media only, indicating very low numbers of organisms. coag neg staph does not require contact precautions, regardless of resistance. 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 _________________________________________________________ staphylococcus, coagulase negative | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ <=0.5 s anaerobic culture (final ): no anaerobes isolated. 10:44 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. 1:00 pm tissue right ischial wound. **final report ** gram stain (final ): reported by phone to @ 630pm . 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. tissue (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. corynebacterium species (diphtheroids). moderate growth. probable enterococcus. moderate growth. pseudomonas aeruginosa. sparse growth. yeast, presumptively not c. albicans. sparse growth. albicans, presumptive identification. sparse growth. pseudomonas aeruginosa. rare growth. second morphology. staphylococcus, coagulase negative. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | cefepime-------------- 32 r 32 r ceftazidime----------- =>64 r =>64 r ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s 2 s meropenem------------- 4 s 2 s piperacillin/tazo----- =>128 r =>128 r tobramycin------------ <=1 s <=1 s anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): albicans. sensitive to fluconazole. sensitivity testing performed by . this test has not been fda approved but has been verified following clinical and laboratory standards institute guidelines by clinical microbiology laboratory.. sensitivities requested by dr . 1:00 pm tissue right thigh wound tissue. **final report ** gram stain (final ): reported by phone to @ 630pm . 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): budding yeast. tissue (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. staphylococcus, coagulase negative. moderate growth. sensitivities per dr . coag neg staph does not require contact precautions, regardless of resistance. 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. enterococcus sp.. moderate growth. sensitivities per dr . daptomycin susceptibility testing requested by k . daptomycin =3mcg/ml sensitivity testing performed by etest. corynebacterium species (diphtheroids). moderate growth. . sparse growth. further workup requested by dr .flash . sensitive to fluconazole , sensitivity testing performed by . this test has not been fda approved but has been verified following clinical and laboratory standards institute guidelines by clinical microbiology laboratory.. pseudomonas aeruginosa. sparse growth. identification and sensitivities performed on culture # , . pseudomonas aeruginosa. sparse growth. second morphology. identification and sensitivities performed on culture # , . sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | enterococcus sp. | | ampicillin------------ =>32 r clindamycin-----------<=0.25 s daptomycin------------ s erythromycin---------- =>8 r gentamicin------------ =>16 r levofloxacin---------- 4 r linezolid------------- 2 s oxacillin------------- =>4 r penicillin g---------- =>64 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ 2 s =>32 r anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): . 4:36 pm blood culture source: line-picc. **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. of two colonial morphologies. aerobic bottle gram stain (final ): reported by phone to @ 720pm . gram positive cocci in pairs and clusters. 12:25 pm swab source: deep right buttocks. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. wound culture (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. pseudomonas aeruginosa. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- =>64 r ceftazidime----------- =>64 r ciprofloxacin--------- 2 i gentamicin------------ 4 s meropenem------------- =>16 r piperacillin/tazo----- =>128 r tobramycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. 12:25 pm swab source: right ischial ulcer . gram stain (final ): no polymorphonuclear leukocytes seen. 3+ (5-10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. smear reviewed; results confirmed. wound culture (preliminary): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. work up requested per dr. . dr () requested doripenem and colistin sensitivities on the 2 ps. aeruginosa isolates . amikacin sensitivity testing per dr flash #, . pseudomonas aeruginosa. sparse growth. doripenem = 12 mcg/ml, non-susceptible, sensitivity testing performed by etest doripenem mic interpretations are based on manufacturer's guidelines that are fda approved. interpret results with caution. isolate sent to laboratories for doripenem confirmation and colistin sensitivity testing (). pseudomonas aeruginosa. sparse growth. strain 2. doripenem = 16 mcg/ml, non-susceptible, sensitivity testing performed by etest doripenem mic interpretations are based on manufacturer's guidelines that are fda approved. interpret results with caution. isolate sent to laboratories for doripenem confirmation and colistin sensitivity testing (). enterococcus sp.. sparse growth. daptomycin sensitivity testing per dr flash #. proteus mirabilis. rare growth. presumptive identification. imipenem requested by dr., at 1135. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | enterococcus sp. | | | proteus mirabili | | | | amikacin-------------- <=2 s 32 i <=2 s ampicillin------------ =>32 r =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- 8 s cefepime-------------- =>64 r =>64 r <=1 s ceftazidime----------- =>64 r =>64 r <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r 2 i =>4 r gentamicin------------ <=1 s 8 i 8 i imipenem-------------- 4 s linezolid------------- 2 s meropenem------------- =>16 r =>16 r <=0.25 s penicillin g---------- =>64 r piperacillin/tazo----- =>128 r =>128 r <=4 s tobramycin------------ <=1 s <=1 s 8 i trimethoprim/sulfa---- =>16 r vancomycin------------ =>32 r anaerobic culture (final ): unable to r/o other pathogens due to overgrowth of swarming proteus spp.. all no growth blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient brief hospital course: ms. had a long (37days) and complicated admission here at . briefly, she was initially admitted on for debridement of gangrenous heel ulcers by surgey, her post operative course was complicated by septic shock multiple mdr organisms (vre, pseudomoas, ), , hypoxia, and neutropenia. a problem oriented list follows with presenation, interventions and follow up for each issue. #heel ulcers: initially, ms. presented to the ed with wet gangrene of her right heel. she is s/p bilateral femoral-popliteal bypasses and a tma of her left foot. she had previously been at a rehab for the infection of her right foot and she was transferred to when they noted its worsening appearance. she was admitted to the surgery service on and was started on vanc and zosyn given her history of mrsa and pseudomonas infection and was taken to the or on hospital day 2 for debridement of her right heel and subcutaneous tissue down to bone. podiatry took her to the or for additional debridement and calcanectomy for osteomyelitis on the following day. the area was resected to create a clean margin of healthy bone. post-op she was noted to become tachycardic, hypotensive and oliguric in the pacu, after which she was transferred to the cvicu for sepsis. she ultimately underwent multiple debridments of her heel by surgery and the wound was dressed with a vac dressing in the interim. on hospital day 9 she was transferred to the vicu. her course continued to be complicated, with respiratory distress, acute renal failure, fluid overload and chf and she was transferred to the medical service on hospital day 15. surgery continued to follow the patient. over the course of her hospital stay, after the initial debridement and calcanectomy the heel wound looked progressively better with good granulation tissue forming. the plan is to continue managing the wound with a vac dressing until it has granulated in. she is unlikely to be ambulatory in the near future and the issue of possible bka can be readdressed at a later date if ambulation becomes an issue. action plan: - continue vac dressing - follow up with as outlined in dc planning . # wound infections: tissue samples and cultures from serial wound debridements grew out multiple multi drug resistant organisms. she is currently on a heavy regimen of iv antibiotics and has a picc line in place to receive them. she is recieving daptomycin for vre, imipenem and tobramycin for pseudomonas, fluconazole for . she is being followed closely by infectious disese at and all questions regarding her antibiotic dosing and monitoring labs should be directed to at . her antibiotics will continue until . detailed dosing/monitoring instructions/ as well as culture data can be found elsewhere in this discharge packet. action plan: - weekly safety labs (see attached) - tobramycin monitoring (see attached) - follow up with id # ischial/thigh ulcers: she was seen by plastic surgery for management of pressure ulcers on the posterior aspect of her thighs bilaterally. they also performed multiple debridements in the operating room as well as at bedside and determined that the dressing for these wounds should be wet-to-dry changes. she should follow up with them in 1 week. action plan: - wet to dry dressings - f/u with plastics in one week . # non- of a left supracondylar femur fracture: she was also seen by orthopaedic surgery for an incidentally found non- of a left supracondylar femur fracture which was sustained in . she previously underwent orif and then 2 revision surgeries. since she had been non-ambulatory prior to admission, she had not been aware of this persistent injury. orthopaedic surgery determined that the patient would not benefit from further revision surgery and recommend that she could undergo knee replacement when medically stable. # hypoxic respiratory failure: patients hyhpoxia was felt to be multifactorial: volume overload, obesity hypoventilation, question of copd. patient was not felt to have had a pe nor a pna as there was no evidece on symtpoms or imaging to support either. she was agressivly diuresed and is currently satting >95% on 2l nc for more than 24 hours. she requires bipap in the evening for osa. her i/o's should be followed closely with a goal of net even to 500cc negative each day. she should also have three times a week chem 7's drawn to monitor her electrolytes. if her cr begins to rise you may adjust her lasix and or fluid restriction as you see fit to maintain her fluid status. her weight on discharge was 151kg. action plan: - i/o's daily: goal even to 500 cc negative - fluid restrict to 1200cc/day - lasix 120mg iv qhs - supplemental o2 prn - nocturnal bipap . # : ms. was admitted with a cr of 1.2, following her bout of sepsis it rose to a peak of 4.4. renal was consulted and although she suffered severe fluid overload she was able to eventually be diruesed and avoided hd. her cr has been gradually correcting and on the day of discharge was 1.8. she is currently making between 30-50cc of urine an hour. as her cr corrects further her antibiotics will need to be adjusted to ensure they are achieving adequate levels in the setting of improving renal function action plan: - trend cr three times a week - continue to diuresis as above until euvolemic; will require close monitoring of volume status - ***ensure antibiotics are renally dosed as kidney function continues to improve . . gram positive bacteremia: on the patient became febrile to 101 and a blood culture grew out staph aureus. the patient was already on broad spectrum gram positive coverage and hd stable. her picc line was removed and surveilance cultures were sent for 3 days with no growth. she remained afebrile throughout her line holiday and after three days a new picc line was placed. she has been afebrile and hd stable since. action plan - monitor vitals . # leukopenia: patient developed neutropenia over the course of her stay with an anc of 0 for several days. she was put on neutropenic precautions and seen by hematology who felt it was secondary to a brief stint on fluroquniolones she received. her abx regimen was optimzed for coverage and she was given neupogen for several days. after resolved after 6 days and her differential and white count has been normal since. action plan - avoid fluroquinolones in the future - weekly cbc with differential while on antibiotics . # cad: s/p cabg x2. trop peaked to 0.37, and has trended down, ck-mb flat and ecg was unchanged. this was thought to be secondary to demand ischemia. her cardiovascular medications wer continued where appropriate. action plan - cont low dose metoprolol - continue aspirin - continue statin . # htn: had required pressors in cvicu, thought to be secondary to sepsis. antihypertensives were held. once off pressors her metoprolol was restarted but at a lower dose. action plan - continue bb; may need to uptitrate as she continues to recover from this acute infection . # diabetes: her sugars fluctuated throughout her stay but her glycemic control was optimzed through basal, meal time and ssi insulin. action plan -- 16 u lantus qam -- 8 units of humalog sc priot to breakfast, lunch and dinner -- ssi humalog at mealtimes: glucose/insulin humalog 71-100 / 0 101-150/ 2 151-200/ 4 -300/ 8 1-400/ 12 >400/ recheck and notify md # anemia: normocytic iron studies c/w aicd. her hct has fluctuated between 22 and 27 throughout her stay. at one point it did drop to 21 although no etiology could be elucidated. she recieved a total of 12 units of prbcs while in house with a transfusion threshold of 21. her hct has been stable for the last 4 days. given that she has no evidence of active bleeding, a stable hematocrit and is asyptomatic at this time we dod not feel that her anemia warrants continued inpatient monitoring. it shoudl be followed closely by her pcp and facility. action plan - three times weekly cbc - transfuse for hct<21 or symptoms of end organ ischemia . # morbid obesity: patient at baseline uses wheelchair. non weightbearing on rle. - dvt ppx with heparin sc medications on admission: aspirin 325 daily, colace 100 , multivitamin, zinc sulfate 220 daily, kcl 10 meq daily, ascorbic acid 500 , ertapenem 1g daily, sq heparin tid, insulin ss, lantus 16units , esomeprazole 50 daily, metoprolol 25mg , miconazole tp, simvastatin 80 daily, trazodone 150 daily, citalopram 40 daily, bacitracin topically to decubitus ulcer, lasix 80mg qam, 40mg qpm, morphine 2mg iv prn, albuterol 2 puffs q4hr prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 3. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed for daily bm. 5. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 6. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 7. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 40 days. 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for yeast. 12. metoclopramide 10 mg tablet sig: one (1) tablet po qid (4 times a day). 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 14. ativan 0.5 mg tablet sig: one (1) tablet po three times a day as needed for anxiety. 15. insulin glargine 100 unit/ml solution sig: twelve (12) units subcutaneous qam. 16. insulin lispro 100 unit/ml solution sig: eight (8) units subcutaneous ac. 17. humalog 100 unit/ml solution sig: subcutaneous ac: per sliding scale. 18. docusate sodium 100 mg capsule sig: one (1) capsule po daily (daily) as needed for hard stool. 19. multivitamin tablet sig: one (1) tablet po daily (daily). 20. daptomycin 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours) for 40 days. 21. imipenem-cilastatin 500 mg recon soln sig: one (1) recon soln intravenous every six (6) hours for 40 days. 22. tobramycin sulfate 40 mg/ml solution sig: one (1) injection as directed for levels less than 1.0 for 40 days: check tobrmycin levels 48 hours following administration. if less than 1.0 re-dose. if >1.0 hold dose and recheck levels daily until <1.0 then redose. 23. furosemide 10 mg/ml solution sig: one y (120) mg injection at bedtime. 24. morphine 100 mg/4 ml solution sig: 1-2 mg intravenous every 4-6 hours as needed for pain: hold for oversedation or rr<10. discharge disposition: extended care facility: - discharge diagnosis: infected ulcers of the bilateral heels, right thigh and ischium. acute kidney injury septic shock hypoxic respiratory failure neutropenia morbid obesity hypertension coronary artery disease discharge condition: + mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. non- weightbearing right lower extremity discharge instructions: you were initially admitted to for debridement of your ulcers on your leg. your hospital course was complicated by a severe infection, kidney failure, respiratory failure and low white blood cells. while you were here your complications were addressed and it is felt that after a long stay you are well enough and stable enough to return to your extended care facility. there were several changes made to your medications while you were here. you are being discharged with an up to date medication list that you and your pcp will review and make changes to as necessasry. you will also have a number of follow up appointments to keep in the next week to months. it is very important that you keep these appointments. followup instructions: department: surgery when: thursday at 2:00 pm with: , md building: lm campus: west best parking: garage department: infectious disease when: tuesday at 3:30 pm with: , m.d. building: lm campus: west best parking: garage department: infectious disease when: wednesday at 9:30 am with: flash, md . building: lm bldg () campus: west best parking: garage name: , location: plastic surgery, pc address: , , , phone: appt: at 10:15am procedure: nonexcisional debridement of wound, infection or burn nonexcisional debridement of wound, infection or burn other myectomy other partial ostectomy, tarsals and metatarsals diagnoses: obstructive sleep apnea (adult)(pediatric) acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension severe sepsis chronic airway obstruction, not elsewhere classified acute on chronic diastolic heart failure aortocoronary bypass status other specified forms of chronic ischemic heart disease acute respiratory failure diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled other specified septicemias septic shock morbid obesity pressure ulcer, buttock carrier or suspected carrier of methicillin resistant staphylococcus aureus surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation other and unspecified infection due to central venous catheter atherosclerosis of native arteries of the extremities with gangrene drug induced neutropenia other specified antibiotics causing adverse effects in therapeutic use nonunion of fracture delirium due to conditions classified elsewhere ulcer of heel and midfoot pressure ulcer, stage iv pseudomonas infection in conditions classified elsewhere and of unspecified site candidiasis of skin and nails other bone involvement in diseases classified elsewhere unspecified osteomyelitis, pelvic region and thigh chronic osteomyelitis, ankle and foot infection with drug-resistant microorganisms, unspecified, with multiple drug resistance other mechanical complication of other internal orthopedic device, implant, and graft pressure ulcer, hip acute glomerulonephritis with unspecified pathological lesion in kidney obesity hypoventilation syndrome 

Answer: The patient is high likely exposed to