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: r toe pain major surgical or invasive procedure: intubation and extubation x3 history of present illness: 79m with history of dmii, cad s/p mi, pvd, copd, hyperchol, htn who was admitted to the vascular surgery service from his cardiologist's office with ~ 1 week of r second toe pain. he had seen his cardiologist on the day of admission for this complaint and his cardiologist advised him to go to the hospital for evaluation because he felt his exam at the time was consistent with ischemia vs. cellulitis. given both his history of dm type ii and cad/pvd, the patient was admitted for iv antibiotics and further workup of his r toe pain. past medical history: 1. copd, with 200 pack-yr smoking hx 2. cad s/p mi, cath with failed ptca/stent rca complicated by dissection and on ivbp 3. pvd, with rle claudication symptoms 4. right hip fx 5. htn 6. hyperlipidemia 7. lung ca s/p rul lobectomy , mediastinoscopy 8. nhl on scalene biopsy 9. ventral hernia repair 10. vre + (confirmed this hospitalization ) social history: married, lives w/ wife in low income housing. has 3 sons who live nearby. used to work as school custodian. + tob (200 pack-yrs). family history: nc physical exam: vs - t 98.1, bp 117/62, hr 73, rr 20, sats 99% on ra gen: nad. neck: + bilateral carotid bruits lung: decreased bs cv: irrr abd: soft, no palpable pulsatile mass/bruit ext: 1+ bilateral fem, + dopplerable dp/pt on l, popliteal r, r dopplerable pt neuro: + sensory, motor intact. pertinent results: labs on admission: wbc 7.6, hct 42.7, mcv 89, plt 182 (diff: neuts-79.5* lymphs-14.6* monos-4.6 eos-0.9 baso-0.4) pt 12.7, ptt 26.8, inr(pt) 1.1 na 138, k 5.6, cl 104, hco3 23, bun 33, cr 1.3, glu 139 . cardiac enzymes: 09:40am blood ck(cpk)-38 ck-mb-notdone ctropnt-0.01 05:00pm blood ck(cpk)-40 ck-mb-notdone 12:50am blood ck(cpk)-36 ck-mb-notdone 12:33pm blood ck-mb-notdone ctropnt-<0.01 (probnp-12,026*) 02:55am blood ck-mb-3 (probnp-6878*) . abg: : 7.06/94/62/28/6, aado2 558, req o2 90, fio2 98%, not intubated : 7.48/42/145/32/7 . labs on discharge: wbc 10.0, hct 36.1, mcv 88, plt 230 na 136, k 4.4, cl 100, hco3 30, bun 29, cr 1.1, glu 132 ca 7.9, mg 2.2, ph 3.3 albumin 2.7 . micro: bcx - negative wound cx (r 3rd toe) - heavy mssa mrsa screen, rectum and nasal - negative ucx - negative rectal swab - + for vre bal - 10,000-100,000 pansensitive pseudomonas dfa - negative dfa and viral cx blood cx - no growth urine cx - no growth blood cx - no growth urine cx - no growth wound tip cx - no growth mrsa screen - negative urine cx - no growth blood cx - pending sc line cx - no growth stool cx - neg for c diff stool cx - neg for c diff . studies: pfts (): fvc 2.58 (77%), fev1 1.83 (83%), fev1/fvc 107%, mmf 1.09 (52%) . foot x-ray (): no bone erosion . arterial duplex (): extensive plaques involving the left common carotid artery and bilateral internal and external carotid arteries with significant stenosis at left internal carotid artery, 80-99%, common carotid artery, 60-69%, and right internal carotid artery, 70-79%. retrograde flow in the left vertebral artery indicating left subclavian steal, significant bilateral iliac, superficial femoral artery and tibial disease. . carotid us (): extensive plaques involving the left common carotid artery and bilateral internal and external carotid arteries with significant stenosis at left internal carotid artery, 80-99%, common carotid artery, 60-69%, and right internal carotid artery, 70-79% . mra les (): 1. moderate-severe atherosclerotic disease of the right common iliac artery, including a focal high-grade stenosis approximately 2.6 cm distal to the aortic bifurcation. there is also moderate-severe disease within the right external iliac and right common femoral arteries. 2. occlusion of the distal right common femoral artery and proximal right superficial femoral artery which extends for approximately 5 cm. the right profunda femorus artery is patent and supplies collateral vessels to the more distal right sfa. 3. diffuse moderate-severe disease of the right superficial femoral artery, with multiple focal stenoses identified. the most high-grade disease is in the region of the adductor canal, focally. the right below-knee popliteal artery od a good quality vessel, and there is normal 3- vessel runoff to the foot. 4. moderate disease of the left common iliac artery with multiple focal stenoses identified. 5. moderate-severe disease of the left superficial femoral artery, with multiple focal stenoses identified. the most severe disease is in the region of the adductor canal. 6. normal 3-vessel runoff on the left. . cxr (): new moderate-sized left and probable small right pleural effusions. dedicated pa and lateral chest radiograph may be helpful for initial further assessment when the patient's condition permits . cxr (): perihilar and basilar opacities are likely due to pulmonary edema. pneumonia is considered less likely. . chest cta (): similar lymphadenopathy in the mediastinum. no evidence of pulmonary embolism. areas of air trapping, ground-glass opacity and slight peripheral septal thickening, suggesting pulmonary venous hypertension or mild congestive heart failure, and perhaps obstructive pulmonary disease as mentioned in the requisition. increased left effusion. calcified posterior wall of left ventricle, unchanged . head ct (): no evidence of acute intracranial hemorrhage or other acute process. . echo (): overall left ventricular systolic function is mildly to moderately depressed with inferior akinesis and basal infero-septal and infero-lateral hypokinesis. ef 40%. inferior akinesis and basal infero-septal and infero-lateral hypokinesis . cxr (): interval improvement in right middle and upper lobe opacities, likely representing improved pulmonary edema . cxr (): worsening pulmonary edema with moderate bilateral pleural effusions. no pneumothorax. . cxr (): endotracheal tube is 8 cm above carina. ng tube is in proximal body of stomach. left subclavian cv line has tip located in region of cavoatrial junction. no pneumothorax. there is a left pleural effusion with associated atelectasis in the left lung zone, unchanged since the prior film of . . cxr (): the superior portion of the chest is obscured by the flexed neck and chin. tip of endotracheal tube is difficult to localize on this film, as is the ng tube. there is a left pleural effusion and ill-defined opacity in the left lower zones consistent with associated atelectasis. left subclavian cv line has tip in region of cavoatrial junction. no definite pneumothorax. repeat film may be obtained for better localization of endotracheal tube and ng tube if clinically indicated. . cxr (): no endotracheal tube present. nasogastric tube ends in a mildly distended stomach. small bilateral pleural effusions improved substantially since . borderline interstitial edema, improved. heart size normal. left subclavian central venous line tip projects over the superior cavoatrial junction. no pneumothorax. status post right upper rib resections. brief hospital course: 79yo m with mmp including dmii, cad s/p mi, pvd, copd, multiple malignancies, hypercholesterolemia, and htn who was admitted to vascular with toe pain, but then developed hypercarbic respiratory failure. . # icu course: mr. presented to his cardiologist's office with 7-10 days of increasing pain in his r foot, specifically his r second toe. his exam at the time was felt to be consistent with ischemia or cellulitis. his cardiologist referred to the hospital and he was admitted to the vascular service. he was started on iv antibiotics (kefzol and flagyl) and a wound culture grew mssa. xr showed no evidence of osteomyelitis. noninvasive vascular studies were performed as the patient was a known vasculopath and it was assumed that an intervention would need to be performed to preserve his toe. studies revealed that he had extensive plaques in the l common carotid artery, bilateral internal and external carotid arteries, as well as significant bilateral iliac, superficial femoral, and tibial disease. there was retrograde flow in the l vertebral artery indicating l subclavian steal. on , while on the vascular service, he developed nausea and vomiting while moving around for all of his studies. he was given reglan and anzemet for his nausea, as well as percocet for his toe pain. he did well until when he began to have labored breathing and a decreased o2 sat to 81%. he was felt to be wheezing and he was given nebulizers with good effect. however, he was then found to be very tachycardic, with a lot of ectopy on telemetry. he was given iv metoprolol for his tachycardia, but overnight, again developed respiratory distress. ekg was unchanged from priors. it was decided to electively intubate him as his rr was in the 30s-40s and his sats were only in the low 90s on a nrb. his abg at the time was 7.14/71/72. he was given 20mg lasix iv and 80mg iv solumedrol, but he remained in respiratory distress so he was transferred to the sicu for intubation. he was sedated and ct of his chest and head were performed to look for causes of his sob. ct of his head revealed no intracranial pathology, and the cta was negative for pe, but did reveal that he had pleural effusions. bnp was elevated at the time, so he was given additional lasix. . mr. was extubated the following evening, with the hope that treatment for chf and copd would have improved his respiratory status. he did well overnight, but again developed tachypnea acutely on the morning of , associated with wheezing and hypoxia. he was given nebulizer treatments x3, solumedrol, and lasix with no improvement. serial abgs at the time revealed 7.35/43/63/25/-1 (post-extubation) -> 7.08/81/62/-8 (during his distress) -> 7.28/41/246/-6(post intubation). on , a tte was performed which revealed left ventricular systolic function of ~40%, which was considered to be moderately depressed with inferior akinesis and basal infero-septal and infero-lateral hypokinesis. an attempt was made at thoracentesis given his bilateral pleural effusions, however the ip team did not feel that they could get a good view through which to tap. an ngt was inserted and tubefeeds were started. on , the decision was made to discontinue the patient's beta-blocker because of increased wheezing. the patient's cardiologist instead recommended using verapamil instead for rate control. . attempt was made at his second extubation on , but again he became acutely tachypneic, tachycardic and hypertensive, with his o2 sats again dropping into the 80s. at this point, he was reintubated and diuresis was continued. cardiac enzymes were cycled x3 and were negative. ep was consulted on and felt that the arrhythmias he was having were consistent with episodes of mat/afib, with no episodes of sustained ventricular rhythms. ep confirmed that the patient needed to be on a beta-blocker, not a ccb, and brought up the issue of anticoagulation. they also recommended continuing with diuresis and attempting extubation again only after his pulmonary edema had resolved. he was also started on afterload reduction with an ace inhibitor. on , a bronchoscopy was performed for further evaluation of his copious, thick, blood-tinged secretions and to see if there is an anatomical reason that mr. was unable to be weaned off the vent. bal culture results were significant for gram negative rods, raising the concern for ventilator associated pneumonia. he performed an sbt on , but developed tachypnea and tachycardia after just 2 hrs. he was then transferred to the micu for help with achieving stable extubation. . in the micu, his antibiotics were broadened to cover for pseudomonas in his sputum (with levaquin and ceftazidime) and he was given vancomycin for gram positive cocci from his r toe (which turned out to be mssa). he was started on an ace inhibitor for improved bp control as well as standing nebulizers and steroids for treatment of his copd. an insulin gtt was added to better control his hyperglycemia. diuresis was continued and his respiratory status improved. he was able to come down to pressure support. he passed a sbt and was extubated successfully on . he was able to maintain his oxygenation with 40-50% fio2 by shovel mask. he was transferred to the floor on and by the morning of , he was down to 2l by nasal cannula. . # pneumonia: he underwent a bal on which grew a pansensitive pseudomonas. mr. completed an 8 day course of ceftazidime (along with 7 days of levaquin, for double coverage initially) for the treatment of pseudomonas ventilator associated pneumonia on . he continued to have a productive cough, but his oxygenation improved. he was able to maintain stable o2 sats of 100% on 2l by nc, but still was mildly hypoxemic on ra (91%). cxr showed that he still has small residual pleural effusions that are resolving. . # copd: mr. likely had a copd exacerbation that contributed to his difficulty in weaning off of the ventilator. however, he was able to be changed from iv solumedrol to po prednisone on the floor. the prednisone taper was started on discharge and his steroids will be slowly tapered over two weeks. he was continued on standing albuterol and ipratroprium nebulizers as he easily became wheezy with any exertion. he was also given albuterol inhalers prn. there was some concern, as above, that his beta-blocker worsened his respiratory status, but the patient seemed to tolerate oral metoprolol without any exacerbation of his copd. . # leukocytosis: mr. wbc began to rise on the floor, at the same time that he began to have diarrhea. given that he was on several antibiotics at the time, there was concern for c diff infection. stool studies were sent x2 and were negative for c diff. he was started on flagyl for empiric treatment of c. diff and cultures were followed. id was consulted for advice in the length of treatment for his pseudomonas pneumonia, as well as advise for the treatment of his r toe. id felt that his ceftazidime could be discontinued after 8 days, that levofloxacin was no longer needed for double coverage, and that his r toe did not look infected, so vancomycin could also be discontinued. ceftazidime was completed on and per id, mr. will be continued on flagyl until . stool cultures were sent, including c diff toxin b, which was still pending upon discharge. . # arrhythmia: mr. was noted to have various sinus arrhythmias in the icu, possibly mat vs sinus tachycardia with ectopic beats. he was given beta-blocker for his tachycardia, but in the icu, there was concern that the beta-blocker was worsening his wheezing and copd, so it was discontinued. verapamil was tried instead, but mr. became very tachycardic without beta-blockade. ep was consulted while the patient was in the icu and recommended discontinuing the verapamil and going back to metoprolol, which the team did with improvement in controlling his rate. on transfer to the floor, mr. was continued on telemetry and appeared to have multiple different rhythms, including mat, sinus tachycardia with ectopic beats (both ventricular and atrial) and ventricular bigeminy. he had episodes of nsvt, maximum of 14 beats, but remained hemodynamically stable and asymptomatic throughout all episodes. his attending recommended increasing the beta-blockade if possible, but his blood pressure was on the lower side, so he was maintained on metoprolol 75mg po tid with adequate rate control. . # pvd: mr. has a long history of claudication. on admission, there was concern for cellulitis vs. gangrene in his r toe. mra showed moderate to severe atherosclerotic disease, but no surgical intervention was planned during this admission due to his tenous respiratory status. mr. prefers to have the summer to heal and would like to pursue whatever intervention is necessary in the fall. dr. is aware of his decision and plans to follow him as an outpatient for now. mr. will follow-up with dr. 2-3 weeks after discharge. . # dm type ii: mr. had been on an insulin gtt in icu, with labile fingersticks. was consulted to help control his hyperglycemia in the setting of acute illness and the administration of tube feeds. on the floor, he was changed back to sc insulin, but became hypoglycemic on the recommended regimen. his steroid use for his copd exacerbation and discontinuation of tube feeds likely contributed to the lability of his glycemic control. he did have a symptomatic episode of hypoglycemia on the morning of which quickly resolved with the administration of 1/2amp of d50. he was discharged on glipizide 5mg daily, which is half of his normal home dose, as well as a humalog insulin sliding scale while he is still on prednisone. his glipizide will be titrated as needed at rehab based on his fingersticks. . # fen: in the icu, he had an ngt through which he was given tube feeds. on transfer to the floor, he was reevaluated by speech and swallow and passed, so he was given a regular, , heart healthy diet with thin liquids and soft solids. he needed no additional ivf upon transfer to the floor. his electrolytes were checked daily and were repleted prn. . # ppx: he received heparin sc for dvt prophylaxis, a ppi for gi prophylaxis, and a bowel regimen prn. . # access: he had a left subclavian line placed in the icu on . he had a picc line placed in his r forearm and the sc line was pulled on . after completion of his antibiotic course, his picc line was pulled and he was able to have a peripheral iv. . # code: full . # comm: and his wife. . # dispo: to rehab. medications on admission: 1. imdur 60mg daily 2. norvasc 10mg daily 3. benecar 40mg daily 4. toprol xl 100mg daily 5. lipitor 10mg daily 6. glucotrol 10mg daily 7. flovent discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) milliliter injection tid (3 times a day): until patient is fully ambulatory. . 6. captopril 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 7. glipizide 5 mg tablet sig: one (1) tablet po once a day. 8. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 5 doses. 9. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 11. prednisone 10 mg tablet sig: varied tablet po once a day: please adhere to the following taper schedule: 60mg daily for 3 days (, , ); 40mg daily for 3 days (, , ); 20mg daily for 3 days (, , ); 10mg daily for 3 days (, , ); 5mg daily for 3 days (, , ). 12. albuterol sulfate 0.083 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours). 13. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours). 14. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 15. insulin lispro (human) 100 unit/ml solution sig: varied units subcutaneous four times a day: as per sliding scale. 16. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 17. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: nursing home - discharge diagnosis: primary diagnosis: r second toe cellulitis pseudomonas ventilator associated pneumonia chf copd . secondary diagnosis: htn pvd dm type ii copd cad lung cancer s/p lobectomy discharge condition: stable. afebrile. bp 122/64, hr 78. rr 20, sats 95% on 2l discharge instructions: please take all your medications as prescribed. your medications have been changed since you've been in the hospital, so please make sure that you are taking only what has been prescribed while in the hospital. . please call your pcp or go to the nearest er if you have any of the following symptoms: fever, chills, chest pain, shortness of breath, difficulty breathing, pain in your legs, pain in your abdomen, worsening diarrhea, nausea, vomiting, or any other worrisome symptoms. . please follow-up with your doctors below. followup instructions: please follow-up with , md on at 10:00am. his office number is . please call if you have any questions or concerns. . please follow-up with dr. (vascular surgery) on wednesday at 2pm. his office number is if you have any questions or need to reschedule this appointment. his office is located at . ( bldg) suite 5c. . please follow-up with dr. (cardiology) on wednesday, , at 11:00am. please call his office at if you have any questions or need to reschedule. . please follow up with dr. for a full physical on at 11:30am. please call his office at if you have any questions or need to reschedule. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus diagnostic ultrasound of other sites of thorax diagnoses: unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension long-term (current) use of steroids diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled atrial fibrillation personal history of malignant neoplasm of bronchus and lung obstructive chronic bronchitis with (acute) exacerbation other malignant lymphomas, unspecified site, extranodal and solid organ sites acute respiratory failure pneumonia due to pseudomonas long-term (current) use of insulin diarrhea atherosclerosis of native arteries of the extremities with ulceration cellulitis and abscess of toe, unspecified 

Answer: The patient is high likely exposed to