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: dyspnea major surgical or invasive procedure: intubation extubation central line placed & removed history of present illness: 48f with copd and htn, presenting to osh with dyspnea and upper abdominal pain. he was recently admitted to osh (2 weeks ago) with 5 day stay for presumed copd exacerbation, ?pneumonia at that time. this started after doing some yardwork outside - thought perhaps had allergy to pollen. sent home on o2, levofloxacin, and prednisone. improved quite a bit at home, but again started feeling unwell yesterday. stayed in bed all day and had poor po intake. wife reports slightly loose bowel movements. also c/o mild abdominal pain and seemed to have worsening breathing difficulties. mild cough. no fevers. at 1 am today, asked his wife to call ems. per wife, has depression but does not believe he would be at risk for od of any type. . he presented to osh. o2 sat in 80s initially, started on bipap and nebs. sats did not improve and looked fatigued, so was intubated. pre-intubation developed hypotension and started on levophed. of note pulse as low as 49 even with hypotension. initial k was 7.5, bnp was 8500. he got lasix, d50, calcium, and possibly kayexalate. also given hydrocortisone 100 mg iv, vanco, zosyn, flagyl. medflighted to . en route hypotension worsened and he was started on dopamine. . in the ed, initial vs were: t97.1 p67 bp114/48 r16 o2 sat 97% on vent. lab derangements include arf, hyperkalemia, combined met/resp acidosis (7.16), transaminitis with hyperbilirubinemia. ct abdomen without contrast performed and showed multifocal pneumonia, equivocal peripancreatic stranding (lipase normal). head ct done prior to transfer - no bleed seen. patient was continued on pressors - currently 0.06 levophed and 15 dopa. also got zosyn here. cvl placed. current vent settings 550 x ?, fio2 1, peep 12, and satting low to mid 90s. . on the floor, patient intubated and unresponsive. per ed, unresponsiveness unexplained and has persisted, ?meds from osh. past medical history: - copd - htn - depression - history of bowel resection and anastamosis due to "kinking" 1.5 years ago - history of chronic back pain s/p surgery x3 social history: - tobacco: quit smoking 1 week ago. generally smokes 1.5-2 ppd, for 30 years. - alcohol: not much in last few weeks; prior was 10 beers per day. wife denies history of withdrawals. - illicits: wife denies, including all inhalants. no recent travel. no unusual hobbies/exposures. wife reports fire down the street that occurred about 3 weeks ago. family history: parents with hypertension. father died of lung cancer. physical exam: general: intubated, comatose, nonresponsive even to pain. heent: sclera anicteric, pupil 5mm and very slightly reactive (4-4.5). mmm, ett in place, difficult to see in op. neck: supple, obese, ij line in place, difficult to otherwise appreciate jvp, no lad lungs: right slightly decreased compared to left, generally coarse but no crackles or wheezes appreciated. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops, abdomen: hypoactive bowel sounds, soft, non-tender, obese but non-distended, no rebound tenderness or guarding, no organomegaly ext: warm ues but feet cool, 2+ pulses, no clubbing, cyanosis or edema neuro: unresponsive to painful stimuli. . on discharge: ambulatory, conversational, diffuse expiratory wheezes, prolonged expiratory phase or respiration, 1+ b/l pitting edema at shins, distant heart sounds. pertinent results: admission labs: 04:00am blood wbc-7.1 rbc-4.06* hgb-13.2* hct-40.0 mcv-99* mch-32.6* mchc-33.0 rdw-14.7 plt ct-144* 08:13am blood neuts-76* bands-16* lymphs-4* monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 08:13am blood pt-16.9* ptt-35.2* inr(pt)-1.5* 08:13am blood fibrino-689* 03:32am blood ret aut-1.9 04:00am blood glucose-158* urean-62* creat-3.0* na-131* k-7.3* cl-100 hco3-19* angap-19 04:00am blood alt-2458* ast-3251* ck(cpk)-1281* alkphos-68 totbili-3.1* dirbili-1.6* indbili-1.5 04:00am blood ck-mb-45* mb indx-3.5 ctropnt-0.01 probnp-6274* 08:13am blood calcium-7.7* phos-7.5* mg-1.7 04:00am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:11am blood type-art temp-36.3 tidal v-500 fio2-100 po2-81* pco2-59* ph-7.15* caltco2-22 base xs--9 aado2-587 req o2-94 -assist/con intubat-intubated 04:10am blood glucose-141* lactate-2.0 na-132* k-5.9* cl-100 calhco3-20* . anemia work-up: 03:32am blood ret aut-1.9 12:10pm blood caltibc-170* vitb12-1693* folate-11.6 ferritn-724* trf-131* 03:32am blood hapto-299* . thyroid: 08:13am blood tsh-0.66 08:13am blood free t4-1.2 . cortisol: 08:13am blood cortsol-56.6* . hepatitis labs: 08:13am blood hbsag-negative hbsab-negative hav ab-positive igm hbc-negative igm hav-negative 08:13am blood hcv ab-negative . discharge labs: 03:03am blood wbc-13.0* rbc-3.34* hgb-11.1* hct-32.2* mcv-97 mch-33.1* mchc-34.3 rdw-16.3* plt ct-211 02:06am blood pt-13.7* ptt-27.9 inr(pt)-1.2* 03:03am blood glucose-77 urean-53* creat-1.2 na-132* k-4.2 cl-94* hco3-30 angap-12 05:31am blood alt-238* ast-56* 02:06am blood calcium-8.0* phos-4.4 mg-1.8 . vancomycin on discharge: 08:10am blood vanco-22.8* (trough) . micro: 4:00 am blood culture site: arm **final report ** blood culture, routine (final ): presumptive peptostreptococcus species. isolated from one set only. anaerobic bottle gram stain (final ): gram positive cocci in pairs, chains, and clusters. . 10:00 pm catheter tip-iv source: right ij. **final report ** wound culture (final ): staphylococcus, coagulase negative. >15 colonies. 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. staphylococcus, coagulase negative. >15 colonies. second morphology. 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 | staphylococcus, coagulase negative | | clindamycin-----------<=0.25 s <=0.25 s erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r =>8 r oxacillin------------- =>4 r =>4 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- <=1 s 2 s vancomycin------------ 2 s 2 s . ct abd/pelvis: 1. dense bibasilar pulmonary consolidations in the lower and less so right middle lobes, most likely reflecting multifocal pneumonia. given the location, component of aspiration cannot be excluded. follow-up with cxr is recommended. 2. mild peripancreatic edema adjacent to the pancreatic head and body. correlation with laboratory evaluation is advised to exclude pancreatitis. 3. aortic atherosclerosis. 4. unremarkable bowel anastomosis in the right lower quadrant. 5. umbilical and inguinal fat-containing hernias. 6. diverticulosis without diverticulitis. 7. age-indeterminate compression fracture of the t8 vertebral body. . cxr: in comparison with the study of , the monitoring and support devices remain in place. there again are multiple areas of increased opacification, especially in the left mid and lower lung zones, most compatible with multifocal pneumonia. small area of similar increased opacification is seen at the right base. this is superimposed upon some engorgement of pulmonary vessels consistent with increased pulmonary venous pressure. there is again prominence of both hila, which could be a manifestation of prominent perihilar edema or possibly enlargement of hilar lymph nodes. . cxr: impression: no evidence of fluid overload. bibasilar atelectasis. . echo: saline bubble contrast study was performed with cough and valsalva release as well as during rest. study was nondiagnostic due to the very suboptimal nature of the images. an intracardiac shunt can neither be ruled in nor ruled out on the basis of this study. consider tee with bubble study. impression: suboptimal image quality. nondiagnostic study . cta: 1. no acute pulmonary embolism or aortic pathology. no evidence of pulmonary avm. 2. mild-to-moderate centrilobular emphysema with upper lobe predominance. 3. improved bibasilar atelectasis. cannot exclude superimposed infection. 4. several scattered small multifocal patchy opacities, could infectious or inflammatory in etiology. mediastinal and left hilar lymphadenopathy, likely reactive. persistent bilateral pleural effusions. 5. unchanged severe t8 compression fracture without acute spinal malalignment . echo: the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: suboptimal image quality. normal biventricular cavity size and global systolic function. mild mitral regurgitation. brief hospital course: 48m with copd and htn, presenting with hypoxic respiratory failure/ards and septic shock. . # ards/hypoxic respiratory failure/pneumonia. appeared to be pneumonia on presentation(aspiration vs. cap vs. hap given recent hospitalization) unlikely to be ards given focal consolidation on initital cxr. the patient was intubated prior to transfer and initially required fairly heavy ventilatory support- ac fio2 1.0 and peep 12 to keep sats in a good range. on hd3 the pt was transitioned to ps from ac with immediate improvement in serial abgs. ps and peep were able to be weaned rapidly, and the pt was extubated on hd4. post-extubation the pt was hypertensive and persistently hypoxic- this was thought to be flash pulmonary edema and responded well to nitro gtt, iv enalapril and lasix. it was thought that his hypoxia was related to a shunt phenomenon, due to the fact that his oxygen saturation did not change with large changes in his supplemental oxygen, a tte was done that was non-diagnostic due to image quality and a cta was done that ruled out a pe. his oxygen requirement continued to decrease and on the day he was transferred to the medical service he was on room air with oxygen saturations in the low 90's. on the floor, hypoxia continued to improve and patient saturated in the low 90s on either room air or 1-2 l nasal cannula. walked with pt, ate, all without sob or desaturation. discharged home with oxygen. . # septic shock. presumed pulmonary source/pneumonia- made more likely with blood cultures growing gpcs, presumably peptostreptococcus. started on broad spectrum coverage with vanc/levoflxacin/zosyn. bps rapidly improved with bolus ivf, weaned rapidly off dopamine then levophed on hd2. bps stable since then, eventually hypertensive which seems to be pts baseline. he completed a 7 day course of levo/zosyn and was transferred to the medical floor with a picc in place to complete a 14 day course of vancomycin for his gpc bacteremia. discharged home with plans for vancomycin administration q24h for 4 days more to complete the course, with pcp monitoring of vanc trough level. shock physiology had resolved, so patient was back on almost all of his antihypertensives (still holding atenolol on discharge) and without hypotension, and with improvement in his laboratory values that had previously been indicating septic shock. . # copd: patient with a history of copd, per his pcp prior to these episodes of pneumonia his pft's did not show severe copd. he was started on steroids, initially solumedrol, he left the icu on prednisone 40mg daily to complete a 14+ day taper. he will need outpatient pulmonary follow up which was scheduled for him, with a better daily regimen, so he was discharged with advair and spiriva and vna for inhaler teaching. . # arf. likely ischemic shock atn vs. prerenal. cr trended down with resolution of sepsis. . # transaminitis. likely shock liver. hep serologies negative. trended down with resuscitation. . # thrombocytopenia. unclear baseline, there seems to be some component of pancytopenia following septic event, gradually trended upward. . # leukocytosis: believed due to steroid administration. plan for outpatient vna check of cbc and faxing to pcp. . # anemia: believed d/t etoh use, septic physiology; not clinically bleeding. recommend outpatient anemia work-up. . # lower extremity edema: believed d/t post-sepsis fluid resuscitated state with fluid settling in legs; recommended leg elevation, ambulation, compression stockings, to help with mobilization of fluid. if not improving, could consider short course of lasix. medications on admission: medications (per osh and list reviewed with wife, though she was not 100% clear on all meds): - prednisone and levofloxacin 750 mg (?completed) - methadone 10 mg - hctz 25 mg daily - clonidine 0.1 mg - lisinopril 40 mg daily - verapamil 240 mg daily - atenolol 100 mg daily - lexapro 10 mg daily - doxepin 10 mg hs - gabapentin 500 mg tid - naproxen 500 mg - albuterol prn - combivent prn . medications on transfer: albuterol nebs captopril 50 tid clonidine 0.1mg doxepin 10mg po qhs colace famotidine 20mg daily gabapentin 300 mg po/ng q8h heparin sq hctz 25mg daily insulin ss ipratropium nebs lactulose q8h prn methadone 10mg metoprolol tartrate 50 mg po/ng tid morphine sulfate 2-4 mg iv q6h:prn pain prednisone 40 mg po/ng daily senna prn vancomycin 1000 mg iv q 12h verapamil 40 mg po q8h . allergies: nkda discharge medications: 1. methadone 10 mg tablet sig: one (1) tablet po bid (2 times a day). 2. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 3. clonidine 0.1 mg tablet sig: one (1) tablet po bid (2 times a day). 4. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 5. verapamil 120 mg tablet sustained release sig: two (2) tablet sustained release po q24h (every 24 hours). 6. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 7. doxepin 10 mg capsule sig: one (1) capsule po hs (at bedtime) as needed for sleep. 8. gabapentin 100 mg capsule sig: five (5) capsule po three times a day. 9. continue 2l nasal cannula home oxygen. 10. vancomycin 1,000 mg recon soln sig: 1250 (1250) mg solution iv intravenous every twenty-four(24) hours for 4 days: starting the morning of wednesday through the morning of saturday . disp:*5000 mg solution iv* refills:*0* 11. compression stocking for bilateral lower extremity edema. 12. prednisone 10 mg tablet sig: see taper below. tablet po once a day for 13 days: 40mg daily on weds . 30mg daily for 3 days (thurs-sat, -15). 20mg daily for 3 days (sun-tues, -18). 10mg daily for 3 days (weds-fri -21). half a tablet daily for 4 days for total of 5mg daily (fri-mon -25). disp:*21 tablet(s)* refills:*0* 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*1* 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulized treatment inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 15. combivent 18-103 mcg/actuation aerosol sig: one (1) inhalation treatment inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation twice a day. disp:*1 diskus* refills:*2* 17. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation inhalation once a day. disp:*30 capsules* refills:*2* 18. outpatient lab work on thursday lab check: vancomycin trough prior to thursday morning's vancomycin dose, cbc, chemistry 7, liver function tests, coagulation panel (pt/ptt/inr). discharge disposition: home with service facility: vna assoc. of discharge diagnosis: multifocal pneumonia copd exacerbation bacteremia shock liver septic shock acute renal failure respiratory failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with respiratory distress, this was believed to be due to a pneumonia and an associated exacerbation of your copd. you were intubated, in the icu, required antibiotics, steroids, and blood pressure support. with these treatments, your respiratory status and overall clinical status improved. . continue to take your regular home medications except change the following: - start a new steroid (prednisone) taper over the 2 weeks - start vancomycin (an antibiotic), given iv once a day, for another 4 days by the visiting nurse team - stop naproxen (you were taking this for pain, but it can injure your kidneys, so don't take it until you follow-up with your primary care physician) - stop levofloxacin/levaquin and azithromycin (antibiotics you had been taking before, and now have completed the courses) - stop atenolol, because your blood pressure has been on the lower side; if you blood pressure is elevated, then you will restart this medicaiton at half dose and then up to full dose as needed - start colace, a stool softener, as needed for constipation - start advair inhalations to treat copd - start spiriva inhalations to treat copd followup instructions: please attend the following appointment with a pulmonologist (lung doctor): . name: , when: wednesday, , 2:15pm specialty: pulmonary location: medical associates address: 1st fl, n. , phone: . thursday , at 2pm - primary care physician : , address: 2621 cranberry hwy, , phone: procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances arterial catheterization diagnoses: pneumonia, organism unspecified hyperpotassemia other chronic pain acute kidney failure with lesion of tubular necrosis unspecified essential hypertension acute and subacute necrosis of liver unspecified septicemia hyposmolality and/or hyponatremia severe sepsis obstructive chronic bronchitis with (acute) exacerbation depressive disorder, not elsewhere classified constipation, unspecified acute respiratory failure septic shock hypoxemia acute edema of lung, unspecified mixed acid-base balance disorder edema 

Answer: The patient is high likely exposed to