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: bactrim attending: chief complaint: shortness of breath, productive cough major surgical or invasive procedure: tee cardioversion history of present illness: 65 yof with history of af not on coumadin due to h/o gi bleed, dchf, as (area 1-1.2cm2), pulmonary htn & osa, morbid obesity, drug resistant pnas, asthma/copd s/p multiple intubations on 2l home o2, who presented with 2-3 days of worsening sob, productive cough and 1 day of ams, was intubated and admitted to the icu in hypercarbic respiratory failure due to pna & decompensated dchf, was extubated , and is now being transferred to for further management of dchf decompensation. . she was discharged from rehab about 2 weeks prior to presentation and according to the patient she was doing well. after discharge from rehab, her baseline was being able to walk from her bed to the kitchen without being significantly short of breath - about 150ft. she noticed a marked decline in her physical capacity 2-3 days prior to admission - about 10-15ft to the bathroom made her sob. . she endorses sick contacts - her brother came to visit about a week prior to presentation and subsequently developed uri symptoms. otherwise, she notes no medicine non-adherence or dietary indiscretion, but say that she occasionally eats canned vegetables, but this has not changed as of late. she denies any recent history of chest pain or palpitations. . in the ed, vital signs were 96.6 110 122/86 24 94 on 4l nc, with abg 7.24/90/72/41 with cxr showing bilateral infiltrates and pulmonary edema. respiratory distress worsened and repeat abg was 7.18/107/89/42 at which point she was intubated and transferred to the icu. . in the icu, her respiratory status improved in the icu. was diuresed on a lasix gtt + metolazone from an admission weight of 141.7kg to 133.7kg (13.8l)on transfer to . for her pna she received vancomycin, meropenem, and azithromycin; vancomycin & azithromycin stopped because cultures grew out gnrs; transferred on meropenem to end . she was also started on a steroid pulse - methylprednisolone 125 mg iv q8h tapered to 80 iv q8h over 3 days; transitioned to prednisone 40 mg daily with taper planned to 10 mg . noted to have leukopenia, id consulted, and presume it to be related to antibiotics. . in the icu prior to transfer, vital signs were 98 92 (afib) 107/66 20 100 3l nc. last abg at 0400 was 7.49/74/113/58. . . <u><b>cardiac review of systems:</b></u> (+) light headedness. (-) denies chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. . <u><b>other review of systems:</b></u> (+) per hpi (-) denies any exertional buttock or calf pain; prior history of stroke, tia, deep venous thrombosis, pulmonary embolism; bleeding at the time of surgery, hemoptysis, black or red stools. . also denies fevers, chills, myalgias, joint pains; cough, wheezes; diarrhea, or recent change in bowel habits; dysuria or change in voiding habits; rashes or skin breakdown; numbness/tingling in extremities; feelings of depression or anxiety. all of the other review of systems were negative. past medical history: <b><u>past medical history:</b></u> <i>cardiac risk factors:</i> (-)diabetes, (-)dyslipidemia, (+)hypertension . <i>cardiac history:</i> - diastolic heart failure, lvef > 55%, - aortic stenosis (valve area 1.0-1.2 cm^2) - moderate pulmonary htn, pcwp > 18 - atrial fibrillation (on dilt +/- beta blocker), no anticoagulation due to history of gi bleeding . <i>coronary artery bypass grafts:</i> none . <i>percutaneous coronary interventions:</i> none . <i>pacing / icd:</i> none . <b><u>other past medical history:</b></u> - asthma: (since childhood)/copd s/p multiple intubations: 2l nc (since ) at baseline for spo2 91-95%, last pft ~1 yr ago at osh, trach previously suggested but pt refused - osa: sleep study in , recommended cpap but has not tolerated it well, unclear how compliant since last discharge (made some progress on the fit of the mask). of note, overnight oximetry "better than expected" when measured at rehab. - gerd - anemia (history of gi bleeding) - leukopenia, long standing, unclear etiology - hyperglycemia when previously on prednisone social history: -smoking/tobacco: quit smoking in (20 pack years) -etoh: none -illicits: none -lives at/with: sister (a nurse) in , was in rehab until ; has 3 children, 1 died @ 27 in from asthma complication, has a daughter who's a . -retired manager of a medical answering services family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. -mother died of cva -father died of lung ca physical exam: admission pe: vitals: as above. general: morbidly obese in nad. alert & oriented x3. mood, affect appropriate. no central or peripheral cyanosis; no jaundice, no palor. heent: ncat. sclera anicteric. perrl, eomi. neck: supple; jvp at mid neck. cardiac: pmi non-displaced. irregularly irregular, normal s1, s2; no s3, s4. moderately high pitched mid-peaking systolic ejection murmur loudest at the rusb radiating to clavicles with preserved s2. no r/g. no thrills, lifts. lungs: coarse inspiratory/expiratory rhonci thoughout, wheezes throughout, no crackles apparent. limited exam due to body habitus. no accessory muscle use. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. groin: no femoral bruits. extremities: no cyanosis, clubbing, or edema. skin: stasis dermatitis, ulcers, scars. pulses: right: dp by doppler left: dp by doppler neuro: cn2-12 intact; moving 4 extremities spontaneously discharge pe: unchanged other than: lungs: scattered low pitched expiratory wheezes but for the most part clear to auscultation with no wet adventitial sounds pertinent results: admission : 11:37pm type-art temp-37.2 rates-18/ tidal vol-450 peep-5 o2-40 po2-105 pco2-77* ph-7.30* total co2-39* base xs-7 intubated-intubated vent-controlled 11:37pm o2 sat-96 08:47pm type-art rates-/21 peep-5 po2-89 pco2-107* ph-7.18* total co2-42* base xs-7 intubated-not intuba 08:47pm o2 sat-93 07:25pm type-art po2-116* pco2-96* ph-7.24* total co2-43* base xs-9 06:53pm %hba1c-5.1 eag-100 06:53pm lactate-1.3 06:30pm glucose-111* urea n-25* creat-1.4* sodium-142 potassium-5.2* chloride-101 total co2-34* anion gap-12 06:30pm estgfr-using this 06:30pm alt(sgpt)-17 ast(sgot)-26 ld(ldh)-305* ck(cpk)-42 alk phos-107* tot bili-0.3 06:30pm ck-mb-3 ctropnt-0.01 probnp-2954* 06:30pm albumin-3.9 calcium-8.6 iron-30 06:30pm caltibc-406 vit b12-420 folate-greater th ferritin-35 trf-312 06:30pm tsh-1.3 06:30pm wbc-5.2# rbc-3.58* hgb-10.4* hct-34.1* mcv-95# mch-29.1 mchc-30.6* rdw-18.2* 06:30pm neuts-82.7* lymphs-10.7* monos-3.3 eos-2.2 basos-1.0 06:30pm plt count-179# 06:30pm plt count-179# 06:30pm pt-13.0 ptt-25.4 inr(pt)-1.1 06:30pm ret aut-5.1* 06:30pm urine color-yellow appear-clear sp -1.010 06:30pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-5.0 leuk-neg 06:08pm po2-72* pco2-90* ph-7.24* total co2-41* base xs-7 . <b><u>ekg:</u></b> -: atrial fibrillation. left posterior hemiblock . <b><u>stress:</u></b> . <b><u>cardiac cath:</u></b> none . <b><u>echocardiogram:</u></b> - tte: impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. aortic stenosis. pulmonary artery systolic hypertension. tricuspid regurgitation. compared with the prior study (images reviewed) of , the severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are slightly lower. the other findings are similar. . - tte: there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). trace aortic regurgitation is seen. impression: mild symmetric left ventricular hypertrophy with normal global systolic function. right ventricular hypertrophy with mild systolic dysfunction. moderate calcific aortic stenosis. mild mitral regurgitation. moderate to severe tricuspid regurgitation. moderate to severe pulmonary hypertension. elevated systemic venous pressures. . <b><u>imaging:</u></b> - cxr port: impression: bibasilar opacities which could represent pulmonary edema or pneumonia. recommend repeat study with optimized technique for accurate evaluation. . - cxr port: impression: ap chest compared to through 23: left lower lobe remains largely collapsed, responsible for leftward mediastinal shift. there is some air at the base, which highlights a small left pleural effusion. edema is clearing from the right lung. pulmonary arteries and veins are dilated, but not as appreciably and small right pleural effusion remains. the heart is quite large but substantially obscured by pleural and parenchymal abnormalities in the left chest. et tube is in standard placement and a nasogastric tube passes into the stomach and out of view. right picc line fluoroscopically positioned in the svc is unchanged. no pneumothorax. . <b><u>micro:</u></b> sputum: achromobacter (alcaligenes) dentrificans amikacin-------------- 32 i cefepime-------------- r ceftazidime----------- 8 s ceftriaxone----------- =>64 r ciprofloxacin--------- 2 i gentamicin------------ =>16 r imipenem-------------- <=1 s levofloxacin---------- 4 i meropenem------------- 8 i piperacillin---------- s piperacillin/tazo----- <=8 s tobramycin------------ =>16 r trimethoprim/sulfa---- <=2 s . discharge : . 05:30am blood wbc-5.1 rbc-3.37* hgb-9.7* hct-28.9* mcv-86 mch-28.7 mchc-33.5 rdw-17.2* plt ct-105* 05:30am blood plt ct-105* 05:30am blood pt-16.2* ptt-84.8* inr(pt)-1.4* 05:30am blood glucose-111* urean-36* creat-1.1 na-142 k-3.2* cl-90* hco3-43* angap-12 05:30am blood calcium-8.5 phos-3.2 mg-1.9 cholest-138 11:21am blood wbc-5.9 rbc-3.29* hgb-9.4* hct-28.6* mcv-87 mch-28.5 mchc-32.9 rdw-17.1* plt ct-142* brief hospital course: 65 yof with history of af not on coumadin due to h/o gi bleed, dchf, moderate as (area 1-1.2cm2), moderate pulmonary htn & osa, morbid obesity, drug resistant pnas, asthma/copd s/p multiple intubations on 2l home o2, who presented with 2-3 days of worsening sob, productive cough and 1 day of ams, was intubated and admitted to the icu in hypercarbic respiratory failure due to suspected pna & decompensated dchf, was extubated , transferred to for further diuresis and rate control. active issues: . # downtrending hct: occult blood positive. hct stable on discharge, with discharge hct of 28.6. **overdue for colonoscopy and will need follow-up scheduled with gastroenterology for colonoscopy by pcp after discharge. anemia were pending on discharge and will need follow-up as well.** . # hypercarbic respiratory failure: intubated in the ed for hypercarbic respiratory failure and transferred to the icu, where she was aggresively diuresed for dchf decompensation as detailed below and a suspected multi-drug resistant pna in light of the patient's history of mdr gnrs on sputum culture. her condition rapidly improved on antibiotics and with diuresis and she was durably extubated and subsequently transferred to the service for further management as detailed below. . # suspected mdr pna: initially treated with vancomycin, meropenem, and azithromycin for mdr pna given the patient's history of sputum growing gnrs sensitive to meropenem during a recent hospitalization. on admission to the icu, sputum cultures were collected and confirmed gnrs, at which point vancomycin and azithromycin were stopped; however, it was not until after the meropenem course was completed that sensitivities showed resistance to meropenem and sensitivity to imapenem. at this point, the patient's clinical improvement was thought to be more likely reflective of her diuresis and steroid pulse for a presumed copd flare rather than a resolving infectious picture. further antibiotics were deferred in the absence of any clinical signs or symptoms of pna, including no leukocytosis, fever, or productive cough. remained afebrile after transfer to . . # copd flare: started on a steroid pulse in the icu for a presumed copd flare in the setting of dchf decompensation - methylprednisolone 125 mg iv q8h tapered to 80 iv q8h over 3 days; transitioned to prednisone 40 mg daily with taper planned to 10 mg, ending . discharged on her home regimen, unchanged, as detailed below. . # (pump) dchf decompensation: on admission had pulmonary congestion on cxr and exam consistent with elevated lvedp. the etiology of the patient's decompensation remains unclear, but it was likely viral uri +/- dietary non-adherence; it is also possible that the patient's af potentiated the decompensation, although her af is chronic. she was admitted at 141.7 kg (312lbs), from a dry weight of 119 kg (262lbs) on discharge . she was diuresed aggressively in the icu with lasix and metolazone and continued diuresis on the floor to her dry weight, being mindful of the patient's preload dependence with dchf/af/mod-as. her discharge weight was 120.9 kg. diuresis resulted in a contraction alkalosis in the setting of chronic metabolic abnormalities as detailed below. discharged on torsemide as detailed below. **potassium will need to be closely followed after discharge and kcl supplementation adjusted accordingly.** . # : diuresis was complicated by cr bump, which showed a trend toward normalization with po intake of fluids. **cr will need to be followed after discharge and torsemide potentially adjusted accordingly.** . # (rhythm) af: rate controlled on her home dose metoprolol 25 mg and diltiazem, which was uptitrated from her home dose of 360 mg daily to 420 mg daily. tee was raised as a potential therapy but ultimately it was decided that the potential benefits of an atrial kick in the setting of chronic af and dchf were outweighed by the risks conferred by anticoagulation subsequent to the cardioversion in light of the patient's history of gi bleed on coumadin. discharged on an increased dose of diltiazem in addition to metoprolol as detailed below under discharge medications. **hr will need to be closely followed after discharge and diltiazem and metoprolol titrated accordingly.** . # coronaries: had no ischemic events this admission. was maintained on home dose asa 325 mg for primary prevention of mi and cva. a lipid panel was sent and showed ldl 74, hdl 42, tg 109, chol 138. . # chronic respiratory acidosis, compensatory metabolic acidosis + contraction alkalosis: admitted in hypercarbic respiratory failure, diuresed, pulsed with steroids, treated with antibiotics, and durably extubated as detailed above. known to be a chronic co2 retainer in chronic respiratory acidosis with compensatory metabolic alkalosis. during diuresis, bicarbonate rose higher than would be expected for chronic respiratory acidosis with compensatory metabolic alkalosis, suggesting a contraction alkalosis. this was managed conservatively with kcl repletion to a goal of 4.5 and intermittent dosing of acetazolamide. bicarb on discharge was showing a trend toward normalization but was still elevated at 40, which near the patient's baseline as of 09/. . # leukopenia: presented with a chronically abnormal cbc with wbc trending in the 2-3 range during her previous admission in 09/. this admission, her wbc nadired at 1.7 and rebounded after discontinuation of meropenem, as predicted by the infectious disease team. . # blurry vision: noted new onset blurry vision without pain or discharge after transfer to ; symptoms did not improve with empiric artificial tears for presumed dry eye. direct ophthalmoscopy showed likely bilateral cataracts. **discharged with ophthalmology follow-up.** . inactive/chronic issues: . # osa: continued home cpap, unchanged. . # gerd: continued home omeprazole 20mg unchanged. . # allergies: continued home fexofenadine 60 mg unchanged. . transitional issues: as above in **. medications on admission: <b><u>medications on admission:</b></u> <i>cardiac meds</i> -diltiazem hcl 360 mg sr q24 -torsemide 40 mg -potassium 40 -metoprolol 25mg -aspirin 325 mg daily . <i>other meds</i> -fluticasone-salmeterol 250-50mcg -tiotropium bromide 18 mcg capsule 1-2 puffs qam -albuterol sulfate 2.5mg nebs q12h prn sob -combivent prn sob -montelukast 10 mg daily -fexofenadine 60 mg -omeprazole 20mg -cholecalciferol (vitamin d3) 400 unit -ferrous sulfate 300mg daily (says now she takes a new dose qid) -calcium carbonate 200 mg (500 mg) tablet -acetaminophen 325 mg tab q6h prn -dextromethorphan-guaifenesin 10-100 mg/5 ml liquid prn -docusate sodium 100 mg -senna discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: caps inhalation daily (daily): qam. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation twice a day as needed for shortness of breath or wheezing. 4. combivent 18-103 mcg/actuation aerosol sig: 1-2 puffs inhalation four times a day as needed for shortness of breath or wheezing. 5. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 6. fexofenadine 60 mg tablet sig: one (1) tablet po daily (daily). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 8. cholecalciferol (vitamin d3) 400 unit capsule sig: one (1) capsule po once a day. 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po once a day. 10. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 12. dextromethorphan-guaifenesin 10-100 mg/5 ml liquid sig: ten (10) ml po every six (6) hours as needed for cough. 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 15. torsemide 20 mg tablet sig: two (2) tablet po twice a day. 16. potassium chloride 20 meq tab sust.rel. particle/crystal sig: three (3) tab sust.rel. particle/crystal po twice a day. disp:*180 tab sust.rel. particle/crystal(s)* refills:*2* 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 18. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 19. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day): sub-cutaneous. disp:* units* refills:*2* 20. potassium please check potassium and fax results to rehab physician. replete potassium per the rehab physician, goal of 4.5. the patient's daily potassium supplementation may need to be increased accordingly. 21. heart rate check please check hr and fax results to rehab physician. patient's diltiazem was increased from 360 to 480 mg daily with the goal hr being < 100 bpm; her rate control meds may need to be adjusted accordingly. 22. check cr please check cr 11/31. peaked at 1.3 and downtrending to 1.2 after encouraging po fluids prior to discharge, baseline about 1.1. fax results to rehab physician. 23. diltiazem hcl 420 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* 24. check hct please check hct , then , then and fax results to rehab physician. has had a slowly downtrending hct with heme+ stool; has a history of iron deficiency anemia on fe supplementation. 25. foley - remove on arrival to rehab patient requested to keep foley in for transport to rehab. d/c after arrival to rehab. discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: primary: -decompensated diastolic heart failure -atrial fibrillation -copd -leukopenia secondary: -moderate aortic stenosis -moderate pulmonary hypertension -gerd -osa 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: it has been a privilege to take care of you at . you were hospitalized because you developed a cough and were short of breath. you were intubated and admitted to the icu in respiratory failure; your chest x-ray showed fluid in your lungs due to heart failure. you were given a medicine to remove this extra fluid and your condition improved. you were also treated for a suspected pneumonia, but in retrospect, you may not have had a pneumonia and your symptoms were likely the result of your heart failure. your breathing was supported on the ventilator until you were well enough to breathe on your own; you were extubated without any problems and transferred to the cardiology floor for further care, where you continued to receive medication to remove the fluid from your lungs. we suspected that your heart failure may have been provoked by your atrial fibrillation, which is a fast irregular heart rate that makes your heart less effective at pumping blood. your cardiologist recommended that this rhythm not be corrected by cardioversion and that your heart rate be controlled with medication. we increased your heart rate medication as detailed below. it is very important that you weigh yourself every morning and md if weight goes up more than 3 lbs. several changes were made to your medications as detailed below. please take your other medications as previously prescribed. # stop: diltiazem 360 mg daily # start: diltiazem 420 mg daily # stop: potassium 40 meq twice daily # start: potassium 60 meq twice daily # start: heparin subcutaneously unless you are ambulating three times a day; this is to decrease risk of deep vein clots please attend the follow-up appointments that we have scheduled for you as detailed below. followup instructions: department: - adult med when: friday, at 3:15pm with: () , md building: (, ma) campus: off campus best parking: free parking on site ****note: please remember to discuss booking a colonoscopy at this appt.**** department: cardiac services when: monday at 2:20 pm with: , md building: sc clinical ctr campus: east best parking: garage department: center when: tuesday at 11:30 am with: , od building: sc clinical ctr campus: east best parking: garage md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube arterial catheterization atrial cardioversion central venous catheter placement with guidance diagnoses: hyperpotassemia obstructive sleep apnea (adult)(pediatric) esophageal reflux congestive heart failure, unspecified acute kidney failure, unspecified atrial fibrillation acute on chronic diastolic heart failure aortic valve disorders other chronic pulmonary heart diseases acute and chronic respiratory failure morbid obesity chronic obstructive asthma with (acute) exacerbation mixed acid-base balance disorder leukocytopenia, unspecified body mass index 50.0-59.9, adult pneumonia due to other specified organism 

Answer: The patient is high likely exposed to