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: sulfa (sulfonamide antibiotics) attending: chief complaint: hypoxia major surgical or invasive procedure: intubation and mechanical ventilation placement of orogastric tube bronchoscopy (multiple) percutaneous tracheostomy placement of percutaneous endoscopic gastrostomy tube picc placement history of present illness: ms. is a 62 year-old woman with a history of hypertension and hyperlipidemia who initially presented to an osh on with pneumonia, now being transferred to for further evaluation of hypoxia. per discussion with hospitalist at osh, patient initially presented to her pcp with cough and sob; cxr at that time reportedly showed no infiltrate; antibiotics were started as an outpatient. then admitted to the osh on with cough and diarrhea and was found to have a lll pna. started on levaquin iv. blood cultures and legionella antigen were negative. a few days into the hospitalization, iv steroids were started. on an abg was obtained and showed 7.48/38/57. a ct was done and showed bilateral infiltrates and no pe; zosyn was started. an echo was also done and showed normal ef and mild pulmonary hypertension. on , iv vancomycin was started. given concern for pcp, was started on day of transfer. given persistent hypoxia, transfer to bimdc was arranged. upon arrival to the icu, the patient reports feeling sob though not significantly worse than prior days. denies chest pains, nausea, vomiting, diarrhea, constipation, abdominal pain. past medical history: 1. hypertension 2. hyperlipidemia 3. hypothyroidism 4. asthma 5. anxiety 6. depression 7. gerd 8. migraines social history: lives with mother. as a personal care assistant and bus monitor (for special needs children). for the former, works with otc chemical supplies. negative for tobacco, alcohol, illicits. family history: mother with asthma, diabetes, breast ca. sister with thyroid ca. physical exam: at admission: vitals: t 96, bp 120/57, hr 91, rr 27, 95% on 70% hi-flow mask gen: ill-appearing, slightly uncomfortable though speaking in full sentences. heent: perrl. anicteric. no pallor. dry mm. no apparent thrush. poor dentition. no cervical lad. cv: rrr. no murmurs appreciated. pulm: diffuse crackles. abd: soft. nt/nd. good bowel sounds. superficial echymoses. ext: warm. trace edema bilaterally. neuro: cnii-xii grossly intact. strength 5-/5 in all four extremitites both distally and proximally. sensation grossly intact to light touch. pertinent results: chest (portable ap) study date of : impression: widespread pulmonary opacities, possibly due to acute widespread pneumonia, but a component of underlying chronic lung disease is suspected. cystic lucencies could reflect underlying emphysema or fibrosis, cavitary pneumonia in the upper lobes is also possible. in the absence of older films for comparison, consider a chest ct for more complete evaluation. bronchial washings procedure date of : bronchial lavage: atypical. clusters of atypical epithelial cells, favor reactive; pulmonary macrophages, neutrophils, and lymphocytes. ct chest w/contrast study date of : impression: 1. diffuse lung opacification, involving all lobes. the pattern is most suggestive of ards. severe infection is another consideration. 2. small right pleural effusion. 3. support lines and tubes as described. 4. coronary artery calcifications. 5. hyperdense material in the nondistended gallbladder may represent sludge, stones, or vicarious excretion of contrast from an outside hospital exam. renal u.s. port study date of : impression: 1. no evidence of hydronephrosis or renal stones. 2. the kidneys are diffusely echogenic, suggestive of diffuse parenchymal disease. unilat up ext veins us left port study date of : impression: partially occlusive thrombus within the left internal jugular vein extending into the subclavian vein and surrounding the indwelling central venous catheter and associated left arm edema. unilat up ext veins us left study date of : impression: interval removal of the left ij catheter with non-occlusive thrombus again demonstrated in the left internal jugular. slightly limited exam but no apparent extension into the subclavian vein. selected lab results: 11:02pm blood wbc-16.6* rbc-3.42* hgb-9.8* hct-29.5* mcv-86 mch-28.5 mchc-33.0 rdw-14.8 plt ct-358 03:50am blood wbc-9.6 rbc-2.61* hgb-7.5* hct-22.2* mcv-85 mch-28.8 mchc-33.8 rdw-15.3 plt ct-231 03:09am blood wbc-8.1 rbc-2.63* hgb-7.8* hct-23.3* mcv-89 mch-29.7 mchc-33.5 rdw-15.7* plt ct-170 04:10am blood wbc-14.3* rbc-2.75* hgb-7.8* hct-23.3* mcv-85 mch-28.3 mchc-33.4 rdw-15.0 plt ct-321 11:02pm blood glucose-124* urean-17 creat-0.8 na-136 k-5.8* cl-102 hco3-26 angap-14 03:23am blood glucose-155* urean-94* creat-3.9* na-136 k-4.6 cl-105 hco3-22 angap-14 02:57am blood glucose-131* urean-27* creat-1.7* na-141 k-3.4 cl-96 hco3-38* angap-10 04:10am blood glucose-127* urean-26* creat-2.0* na-134 k-4.4 cl-91* hco3-31 angap-16 11:02pm blood alt-21 ast-46* ld(ldh)-797* alkphos-76 totbili-0.4 03:51am blood alt-14 ast-18 alkphos-86 totbili-0.2 05:13am blood anca-negative b 05:13am blood -positive titer-1:80 microbiology: blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient mini-bal gram stain-final; respiratory culture-final {staph aureus coag +}; fungal culture-preliminary inpatient blood culture blood culture, routine-final {staphylococcus, coagulase negative}; aerobic bottle gram stain-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient sputum gram stain-final; respiratory culture-final {staph aureus coag +} inpatient blood culture blood culture, routine-final inpatient urine urine culture-final {yeast} inpatient sputum gram stain-final; respiratory culture-final {yeast, staph aureus coag +} inpatient catheter tip-iv wound culture-final inpatient sputum gram stain-final; respiratory culture-final {yeast, staph aureus coag +}; fungal culture-final {yeast} inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient bronchoalveolar lavage gram stain-final; respiratory culture-final {staph aureus coag +}; acid fast culture-preliminary; acid fast smear-final; fungal culture-final; potassium hydroxide preparation-final; immunoflourescent test for pneumocystis jirovecii (carinii)-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient sputum gram stain-final; respiratory culture-final {staph aureus coag +}; fungal culture-final {yeast} inpatient mrsa screen mrsa screen-final {staph aureus coag +} brief hospital course: events: - intubated due to low pao2 on 100% and work of breathing - arterial line & left ij cvl placed for bp monitoring & access - ct scan deferred while improving ventillation and decreasing pips & plateau pressures - steroid taper written - insulin sliding scale written (on steroids & d5 ivf) - still need to f/u hiv test from osh events: - difficulty ventilating this morning - persistent hypercarbia, acidosis. paralyzed. tweaked vent setting (rr 42, vt 280). abg improved. - hiv test not done yet at osh - will fax results on monday - ct chest: ards - ordered ativan atc - bal done; 1+ pmns - sputum showing 1+ gpc - uop low, was given ivf boluses. responded well with increased uop. (however did not response to lasix challenges earlier in the day) events: - anca negative, hiv pending - started fentanyl patch at 100mcg/hr, started fentanyl/versed gtt, propfol and cisatracurium weaned off without complications. - urine studies negative. ueos neg, una<10. continued fluids - bladder pressure 12. - bal pcp neg, afb neg, fungus neg - consider tube feeds events: note: use lr for prn boluses - started phos binder - 1l lr bolus at 1400 for decreased bp - nephrology consulted and rec no additional lr and suggest 150 meq bicarb, discontinue topamax, renal us, and repeat urine lytes - nephrology additionally noted muddy brown cast in urine sediment - nutrition rec novasource renal with beneprotein additive for tube feeds - bal from returned as mrsa events: - limited fluid bolus with 1l d5w 3 amp bicarb-water - unable to lighten sedation due to becoming dyssynchronous - discontinued cefepime events: - renal recs no dialysis at this point - steroid taper written - increased fentanyl patch to 200mcg/hr events: - patient had a cuff leak around high endotracheal tube in morning. was repositioned over bronchoscope. - around this event the sedation requirement was increased. - patient received 150 meq hco3 in d5w for low urine output - vent setting tidal volume increased to 260 in the morning with evening abg 7.34/52/85 - hypoxic briefly in middle of night and abg drawn 7.31/55/65, peep increased slightly to 12 events: - transfused an additional 2 units - ultrasound showed clot in left ij and subclavian associated with line, which was pulled. patient had elevated ptt (65) without heprin gtt. a repeat confirmed this and so heparin sc was started and the drip held. - sedation weaned and patient began to over-breathe, also sbp elevated to 180's. went back up slightly on fentanyl. events: - renal recs if pulm prognosis worsening, dialysis could be futile, no new recs - midline d/c, picc consult placed - decreased fentanyl sedation - vanco 1 gm x1 - able to wean vent to fio2 60% events: - picc line placement complicated by traverse into rij, was pulled back to midline position, plan for ir picc on - patient with desats to 90% while appearing to be synchronous, fio2 increased back to 70% as peep increase caused unacceptable peak airway pressures in past events: - postponed ir repositioning of picc given tenuous status - increased methadone/sedation to attempt to decrease pip - plan to begin diuresis if renal function improves events: - ip consulted for trach/peg, rec likely monday if fio2 down to 50% and peep at least 8 - improved cr to 2.6 in pm, started diuresis with lasix 10 iv then 20 iv, no uop intially; however, good uop with foley repositioning - lupus/anti-phospholipid ab pending - ptt cont elevated, plan heparin gtt if ptt<60 - vanco x 1 dose given - briefly on pressure control ventilation with abg taken - picc line started events: - was diuresed with bolus furosemide with good effect, evening cr was 2.6 - bowel regimen was productive of two large soft bowel movements events: - repeat upper ext. ultrasound to follow clot burden events: - ett at carina, pulled back, rpt cxr good position - inc diltiazem 60mg qid - heme recs no iv hep, no lovenox d/t renal function, watch ptt on sc heparin - increased free water d/t hypernatremia to 150ml q6 - fluc 150mg po x1 given for vag candidiasis events: - evening ptt was elevated to 103.6 and midnight heparin injection was held - ip stopped by to see patient and reported they would be back to re-evaluate patient for possible trach and peg for ; however, she is likely to need surgical airway in or if she has ongoing fio2 elevated above 50% and peep > 8 - tube feeds were stopped due to high residuals and then ng tube put to wall suction with return of ~200 ml of yellow liquid. tube feeds were restarted at 0500. events: - able to wean ventilatior in assist control mode to peep 5, and fio2 55% - lupus anti-coagulant positive and low heparin level, likely not anti-coagulated on heparin subcutaneous alone (cannot rely on ptt). since likely going to procedure, ok for now, however will need plan for anticoagulation after trach and peg. events: - ip recs trach/peg likely thursday - bronch performed and sig for et tube against trachea, repositioned with improvement in pip - heme recs start hep gtt, follow heparin levels (0.3-0.7 therapeutic), anti-coag x1 month, f/u dvt with ultrasound in 1 month, heme f/u 3 months with rpt la/apl - heparin level changed from < 0.13 to 0.25 after initiation of heparin drip - increased fio2 to 70% due to desat while turning events: - fio2 titrated back down to 55% - bronch performed to reposition et tube - heparin drip titrated up and found to be therapeutic at 700 units/hr - overnight had high pips; however, attributed to et tube positioning and not related to desats. patient repositioning attempted; however, no change in pips. sedation appeared adequate at pulse an bp were within normal range. - tube feeds were off at midnight - heparin drip turned off at 0400 on events: - trach and peg at bedside in evening. got portex, and has had elevated peaks since then. was a difficult procedure per thoracic surgery. - abg this morning was 7.43/59/52 with high peak and fio2 was increased to 80% - thoracic surgery reports it is okay to start tube feeds tonight around 10pm events: - heme recs if cr improves can do lovenox, anticoag x1m, rpt u/s and la 1 month, if still + rpt la in 12wks. sign off. - trach site with onset of blood oozing during afternoon, hep gtt turned off. - thoracics eval, recs cont d/c hep gtt x36hrs - continued high pip, no change in resp mechanics with peep to 10, put back to peep 5. o2 weaned down. - tube feeds restarted at midnight events: - patient remained on pressure control with fio2 of 70% and inability to titrate down - had peep increase from 5 to 8 due to abg with po2 of 56 this morning events: - heparin drip turned back on at 0400 - decreased sedation (methadone down to 30mg q4 from 40mg q4) - patient became more alerted and would blink eyes to command - switch to pressure support - had temp to 101.1 and tachycardia and hypertension, got blood and urine culture. did not have increased secretions and is known colonizer of mrsa so did not get repeat sputum. events: - continued pressure support ventilation events: - was started on linezolid, zosyn, cipro due to new fevers, increased secretions, worsening cxr, and worsening hypoxia - one out of two blood cultures returned as positive for gram positive cocci in clutsters (later speciated as coagulase negative staph) - new blood cultures drawn for surveillance - mini-bal performed - called her sister, , in the evening to let her know about new infection and she will be in for family meeting in early afternoon on - patient with sats in low 90s overnight and was difficult to ventilate, was on volume control for several hours, had abg of 7.38/64/46 early morning of ; switched to pressure control and fio2 increased to 100% and abg redrawn to show 7.36/69/53 - morning hct was down to 21.3 so transfused 1 unit prbcs - urine lytes sent due to low uop and slight increase/plateau in cr events: - transfused 1 unit with appropriate increase in hct. - continued diruesis with lasix - family meeting discussing new infection and poor prognosis. family stated the patient would like to do everything and they would like to reassess in a couple of days. - placed on lasix drip with poor response, free water flushes decreased. - added diuril 500 mg iv bid to attempt diuresis - worsening abg: 7.32/75/46 despite increasing vent settings. called family to ask them to come in early on . repeat abg: 7.25/85/47. events: - oxygenation became exceeding difficult via the vent despite 100% fio2 and high peep up to 22 - patient intermittently bagged to maintain oxygen sats - family made pt , extubated patient and she expired at 14:31 medications on admission: medications (home): klonopin 2mg daily avapro cardia imiprimine 200mg qhs atorvastatin levothyroxine . medications (transfer): 750mg vancomycin 1g q12 prednisone 50mg daily kcl 40mg daily zosyn 3.75 q6h omeprazole 20mg nystatin s&s avapro 150mg daily advair 250/50 zomig 5mg daily duonebs prn topamax 25mg heparin sc tid simvastatin 20mg daily cardizem cd 180mg daily synthroid 0.112mg daily ambien 5mg qhs prn klonopin 2mg daily imiprimine 15mg qhs discharge medications: none, patient expired. discharge disposition: expired discharge diagnosis: primary: mrsa pneumonia acute respiratory distress syndrome secondary: left upper extremity deep vein thrombosis lupus anticoagulant positivity discharge condition: patient expired. discharge instructions: patient expired. followup instructions: patient expired. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube fiber-optic bronchoscopy non-invasive mechanical ventilation percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus injection or infusion of oxazolidinone class of antibiotics diagnoses: acidosis pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified unspecified acquired hypothyroidism other chronic pulmonary heart diseases dysthymic disorder acute respiratory failure hypoxemia carrier or suspected carrier of methicillin resistant staphylococcus aureus dependence on respirator, status methicillin resistant pneumonia due to staphylococcus aureus 

Answer: The patient is high likely exposed to