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: penicillins attending: chief complaint: altered mental status respiratory distress major surgical or invasive procedure: endotracheal intubation and extubation flexible bronchoscopy history of present illness: mr. is a 55-year-old male with pmhx significant for chf, recurrent pna, rectal ca with colostomy in place, seizure d/o, mdd, mr, copd, cirrhosis, schizophrenia and glaucoma who presented to osh with hypoglycemia, altered mental status and respiratory distress. patient was noted to be obtunded at nursing home this morning; fingerstick glucose 40. got d50 and ems was called; emts noted respiratory distress and he was taken to an osh where cxr showed pulmonary edema and possible pneumonia. he was also noted to have a valproate level of 95 (upper limit of normal for that assay: 20) and ammonia 214. patient continued to have respiratory distress so he was intubated and started on ceftriaxone & azithromycin empirically for pna. received nitroglycerin and lasix 20mg iv with increase in uop. given respiratory status and concern for valproic acid overdose, patient was transferred to for further management. en route to , he became hypotensive to sbp 80s and was started on levophed. pressors were stopped on arrival to (and patient has remained off of pressors with sbps 110s-130s). vs on arrival to the ed were f 68 133/69 16 100% fio2 100%. fast exam negative; bedside cardiac ultrasound showed hypokinesis with poor contractility, no ivc collapse. troponin <0.01 x 1. cxr showed pulmonary edema and patchy opacities concerning for pna. rij placed and patient got a dose of vancomycin for empiric hcap coverage (lives in nursing home). bnp elevated at and u/a positive for uti. given concern for valproate level at osh (95, normal range 50-100), toxicology was consulted; however, his repeat valproate level was 72, which is within normal range of 50-100 for our lab. patient received 1 dose of multidose activated charcoal as well as l-carnitine 5 grams via ngt (maximum dose 6g/day) and was admitted to the micu for further management of respiratory failure. past medical history: -chf (diastolic) -copd -recurrent pna -rectal ca with colostomy in place -seizure d/o per report -mdd -cognitive delay/mr -schizophrenia -bipolar disorder -glaucoma -hypothyroidism social history: tobacco: none. alcohol: sister/hcp reports prior history of heavy alcohol use. illicits: none. family history: non-contributory physical exam: on admission: vs: t: 37.7 ??????c (99.9 ??????f)hr: 85 bp: 117/63(76) rr: 18 spo2: 95% on ventilator mode: cmv/assist/vt (set): 450 ml rr (set): 18 peep: 8 cmh2o fio2: 60% general: intubated, sedated no acute distress heent: ncat, l pupil 5->4mm brisk, r pupil 3->2mm & sluggish, neck: rij, no lad lungs: + (palpable) rhonchi, no wheezes or rales cv: regular rate and rhythm, normal s1 + s2, ii/vi diastolic murmur heard best at lusb, rubs, gallops abdomen: soft, non-tender, non-distended, hypoactive bowel sounds, no rebound tenderness or guarding, no hsm appreciated gu: foley ext: feet pale & cool, hands slightly warmer, 2+ dp pulses b/l, 1+ pt pulses b/l, trace ankle edema bilaterally, no clubbing or cyanosis neuro: moving toes and squeezing fingers to command . on discharge: o: tm 99.4 tc 97.4 hr 106-117 bp 158-173/86-106 rr 18-20 spo2 95% on 3l/ra gen: obese male lying in hospital bed, pleasant and in nad. heent: eomi, mild anisocoria of l-pupil, mmm cvs: rrr, no m/r/g, s1, s2 pulm: mild ronchi, expiratory wheezing (pt was about to receive standing albuterol neb) abd: soft/nt/nd, colostomy bag in place ext: 2+ pulses, no edema skin: dry, no rashes or lesions pertinent results: 03:06am blood wbc-3.8* rbc-2.76* hgb-8.9* hct-26.5* mcv-96 mch-32.2* mchc-33.5 rdw-16.9* plt ct-155 03:06am blood plt ct-155 03:06am blood glucose-88 urean-14 creat-0.5 na-143 k-4.0 cl-98 hco3-42* angap-7* 03:06am blood calcium-9.2 phos-3.2 mg-1.8 on admission: pt-12.1 ptt-25.7 inr(pt)-1.0 wbc-7.7 rbc-2.99* hgb-9.7* hct-29.2* neuts-83* bands-0 lymphs-12* monos-5 eos-0 basos-0 plt count-277 valproate-72 ctropnt-<0.01 probnp-* lipase-12 alt(sgpt)-14 ast(sgot)-11 ld(ldh)-267* ck(cpk)-14* alk phos-62 tot bili-0.3 glucose-60* urea n-16 creat-0.4* sodium-146* potassium-3.8 chloride-97 total co2-40* anion gap-13 urine rbc-5* wbc-58* bacteria-few yeast-none epi-0 urine blood-tr nitrite-pos protein-100 glucose-neg ketone-40 bilirubin-neg urobilngn-neg ph-7.0 leuk-mod lactate-1.0 . microbiology: urine: 10,000-100,000 of klebsiella, pan-sensitive except nitrofurantoin blood cx: still pending as of mrsa screen: negative and c-dif toxin: negative catheter tip iv: negative sputum: gpc's in pairs and clusters on gram stain; cx showed sparse pan-sensitive pseudomonas . imaging: transthoracic echo: the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. overall left ventricular systolic function is near-hyperdynamic (lvef 70-75%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. impression: near-hyperdynamic left ventricular systolic function. no pulmonary hypertension or clinically-significant valvular disease seen. . ct head w/o contrast: no evidence of acute intracranial process. . cxr: substantial left lower atelectasis which worsened appreciably between and has continued to progress, now accompanied by moderate left pleural effusion which may be responsible for a new bulging contour in the mediastinum in the region of the aortopulmonic window. there is also new substantial right lower atelectasis. et tube is in standard placement. nasogastric tube passes into the stomach and out of view. no pneumothorax. right internal jugular line ends in the mid svc. . cxr: mild resolution in the rigth lower atelectasis/consolidation, left basal atelectasis and bilateral pleural effusion. . cxr (12pm - discussed with radiologist, report not available): increased opacity in left lower , represent an aspiration pneumonia. no pneumothorax. cxr (3pm - disucssed with radiologist, report no available): taken after pt had chest pt, somewhat improved opacity in left lower , new opacity still present compared to cxr. no pneumothorax, no pleural effusion. urine culture (final ): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 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-------- 64 i tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: 55-year-old male with pmhx significant for chf, recurrent pna, rectal ca with colostomy, seizure d/o, mdd, mr, copd, cirrhosis, schizophrenia and glaucoma who presented with hypoglycemia, altered mental status and respiratory failure likely secondary to chf exacerbation & possible pna, found to have a urinary tract infection. . # respiratory failure: a cxr at an osh showed moderate pulmonary edema consistent with a chf exacerbation. the pt received nitroglycerin and lasix 20mg iv at the osh, with increased urine output. his bnp was (his baseline is unclear). in the icu here we continued diuresis given his h/o chf and moderate fluid overload, and we monitored his bp closely. his cxr also had opacities concerning for infection; however, the patient has been afebrile and without leukocytosis. he received ceftriaxone 1g and azithromycin 500mg at the osh, and got 1g vancomycin additionally at the ed for empiric hcap coverage given that patient lives at a long-term care facility. his initial abg was consistent with compensatory metabolic alkalosis superimposed on chronic respiratory acidosis secondary to copd. his sputum gram stain had shown gpc's in pairs and clusters, and the cx showed sparse pan-sensitive pseudomonas. thus his antiobiotic treatment was narrowed to cipro alone with standing albuterol. he was extubated on and remained stable on 4l nc. upon transfer to the floor, he continued to receive standing albuterol nebs q4h with additional prn nebs for dyspnea. on , he had an episode where he desaturated to a presumed aspiration pneumonia. he was given a non-rebreather and his albuterol nebs were changed to q2h standing. after this, his oxygen was at one point weaned to 2l, which is his baseline requirement. on , he was noted to desaturate and had decreased breath sounds on the left side. a stat cxr showed increased opacity of the left lower lung with no pneumothorax and no pleural effusion, this was thought to represent mucous plugging vs aspiration. he received chest physical therapy and a repeat cxr was taken which was somewhat improved, but a new left lower opacity remained present. his oxygen saturation improved to 95% on 3l nc, he was noted to have a low grade fever of ~100f. his health care proxy was updated daily about his clinical status and palliative care was consulted. both the patient and his hcp wanted to transition goals of care towards a quality of life approach and avoid any further aggressive measures. pt wanted to advance a regular diet despite his chronic aspiration pneumonias with the knowledge that he will continue to aspirate and would prefer to managed conservatively with palliative care/hospice following for symptom management. # acute toxic metabolic encephalopathy: the etiology of this problem was likely multifactorial. he was found obtunded at his nursing home with a blood glucose of 40. he has no known history of dm2; however, his sister/hcp states that he does occasionally get insulin at the nursing home. he was also found to have a urinary tract infection in addition to possible pneumonia, thus delirium secondary to infection likely contributed to his altered mental status. there was initial concern for valproate toxicity, but the patient's levels were 95 and 72, both within normal limits for vpa level (50-100mg/l). he was evaluated by toxicology and received 1 dose of multidose activated charcoal in addition to 5 grams of l-carnitine. his ammonia level was elevated to 214; however, the patient reportedly has cirrhosis and it is unclear how much this correlates to his ams. he had a non-contrast head ct at the osh which was of poor quality; given his anisocoria of unknown duration in the context of acute mental status change, we obtained a repeat head ct which showed no acute intracranial process. additionally, the patient has a known seizure disorder. while his valproic acid levels are currently therapeutic, an eeg was obtained on to rule out status epilepticus or subclinical seizure activity (results still pending as of ). we continued his home dose of depakote and treated his uti and pna as described above. his mental status resolved back to his baseline per his sister's report. at the time of discharge, he is alert, interactive and oriented x3. . # hypotension: the patient was hypotensive to sbp 80s while being transported to & was started on levophed; it was stopped on arrival to our ed and since then his bps have been 110s-130s off pressors. the patient has a history of chf and presents with cardiac hypokinesis & decreased contractility on bedside cardiac u/s; however, his baseline cardiac function is unknown. there is no evidence of ivc collapse on u/s. his troponin was <0.01 x 1. distributive/septic shock was possibly a factor given his uti and likely hcap, however patient was afebrile with normal wbc and lactate 1.0. additionally, the patient is on prednisone daily for management of copd; adrenal insufficiency was also considered in the context of increased physiologic stress, but the pt did not become hypotensive again. on the floor, his bp remained stable and was somewhat elevated to the 140-150s systolic because his home metoprolol and lisinopril were held due to his hypotension upon presentation. we restarted his metoprolol on , he may need to have his lisinopril restarted once his pressures are observed to be stable on metoprolol. . # uti: u/a was positive with 58 wbc, few bacteria and 0 epis. patient had already received a dose of ceftriaxone at the osh and his initial urine cx was positive klebsiella. pt was covered with ciprofloxacin and should complete a 14 day course on . . # anemia: his hct here was hct 29.2 on arrival and remained stable. his baseline hct is unclear. there was no evidence of bleeding and his t.bili was 0.3 so hemolysis seems unlikely. at discharge, his hct was not significantly changed at 26.5. . #seizure disorder: he had an eeg to evaluate for the possibility of seizure activity contributing to his initial altered mental status. the eeg showed no seizure activity, only evidence of a toxic encephalopathy. he was continued on valproic acid. . #dysphagia: pt was felt to be a continued aspiration risk. it was decided with the patient and his healthcare proxy that despite the risk of aspiration, he would be advanced to a regular diet for quality of life. . #schizophrenia: he was continued on seroquel for his schizophrenia. his morning dose was changed from standing to prn and was held for sedation. he was more alert and interactive in the mornings with this medication change. . #goals of care: discussions with patient and family to clarify goals of care resulted in a code status of dnr/dni and do not hospitalize. they wanted to focus care on managing his symptoms with chest pt, duonebs, supplemental oxygen and morphine as needed for respiratory distress. . #transitional issues: -will need cipro discontinued on -will need further discussion with patient family regarding goals of treatment as new issues arise -new opacity noted in left lower , likely aspiration pneumonia -code status established as dnr/dni and do not hospitalize -his home dose of lisinopril is currently being held. if lisinopril, will need renal function and serum electrolytes monitored medications on admission: divalproex ext-release (depakote er) 1000mg po bid prednisone 10mg po qd omeprazole 20mg po qd lisinopril 20mg po bid metoprolol tartrate 50mg po bid levothyroxine sodium 25mcg po qd doxepin hcl 100mg po qhs fluoxetine hcl 60mg po qd quetiapine fumarate (seroquel) 50mg po bid quetiapine fumarate (seroquel) 100mg po qhs acetaminophen 325mg po bisacodyl supp (dulcolax) 10mg pr prn hydrocodone 5/apap 500 (vicodin) 1 tab po prn albuterol 3/ipratropium 0.5 (duoneb) 1 vial inh prn discharge medications: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 3. fluoxetine 20 mg/5 ml solution sig: fifteen (15) ml po daily (daily). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day: hold for sbp<110, hr<60. 5. bipap inspiratory pressure: 12 cm/h2o expiratory pressure: 6 cm/h2o supp o2: 4 l/min 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. depakote er 500 mg tablet extended release 24 hr sig: two (2) tablet extended release 24 hr po twice a day. 8. tylenol 325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 9. bisacodyl 10 mg suppository sig: one (1) rectal twice a day as needed for constipation. 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po every twelve (12) hours for 3 days. 11. duoneb 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) inhalation every 2 hours as needed for shortness of breath or wheezing. 12. doxepin 100 mg capsule sig: one (1) capsule po at bedtime. 13. duoneb 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) inhalation every four (4) hours. 14. quetiapine 50 mg tablet sig: three (3) tablet po at bedtime. 15. quetiapine 50 mg tablet sig: one (1) tablet po each morning as needed for agitation. 16. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: five (5) mg po every 1 hour as needed for mild pain. disp:*10 ml* refills:*0* 17. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: ten (10) mg po every 1 hour as needed for moderate pain. disp:*10 ml* refills:*0* 18. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: fifteen (15) mg po every 1 hour as needed for severe pain. disp:*10 ml* refills:*0* discharge disposition: extended care facility: life care center of - discharge diagnosis: primary disgnoses: respiratory failure aspiration pneumonia dysphagia uti secondary diagnoses: seizures schizophrenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital with difficulty breathing and low blood pressures. you were intubated until your breathing improved and you could be extubated. you were initially given medicines to maintain a normal blood pressure, which eventually stabilized. . you were also given antibiotics for a urinary tract infection and pneumonia. your last dose of the antibiotic, ciprofloxacin, will be on . . palliative care was consulted and they helped you arrange for hospice care after discharge. you decided that you would not like to be hospitalized in the future after discharge and you would not want to have a breathing tube placed and would not like to be resuscitated in the event of a medical emergency. . metoprolol and lisinopril were initially stopped while you were in the hospital because of your low bp at that time. we have restarted the metoprolol. after discharge, you will need to have your blood pressure monitored, and your doctors should consider lisinopril. if lisinopril is restarted, your kidney function and electrolytes will need to be monitored. . your morning seroquel dose was also changed so that it was only given if you are agitated. . the following changes were made to your medications: start cipro 500mg two times per day until start oxycodone 5-10ml of 5mg/ml liquid every 4 hours as needed for pain or shortness of breath continue seroquel 150 mg at night. stop seroquel 50mg po in the morning, give only if agitated. stop lisinopril stop vicodin followup instructions: please follow up with your primary care provider as necessary. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances diagnoses: anemia of other chronic disease urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified acute on chronic diastolic heart failure unspecified schizophrenia, unspecified pulmonary collapse acute and chronic respiratory failure pneumonia due to pseudomonas pneumonitis due to inhalation of food or vomitus personal history of malignant neoplasm of large intestine epilepsy, unspecified, without mention of intractable epilepsy encounter for palliative care do not resuscitate status colostomy status mild intellectual disabilities dysphagia, unspecified 

Answer: The patient is high likely exposed to