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: no known allergies / adverse drug reactions attending: chief complaint: found down major surgical or invasive procedure: intubation and extubation central line placement and removal picc line placement history of present illness: 77 yo f with no known medical history found down in bathroom in her home. family had not heard from patient in several days, called the neighbor and asked them to check in on her. neighbor had hard time getting into apartment and called ems. ems found patient in a dirty home, cluttered, "hoarding environment" and found pt lying on bathroom floor on right side with vacuum on top of her. she was awake, able to tell them she had pain everywhere. gcs 13 per ems. went to first, had negative head and cspine ct. plain films of lower extremities negative, she was then transferred to for further workup. in , pt noted to have numerous pressure ulcers, specifically on the right side. has dark urine. in the ed inital vitals were, bp 70s--> given 2 l, intubated her for hypotension and minimally responsive mental state. t 34.5, 115, 99/65, 100%v vt 450, r14, peep5, 50% fi02. she was found to be in afib with rvr, hr 166 given dilt 10mg x2-->119. pt wth hypothermia, t 34.5, had barehugger. concern for sepsis and given zosyn here, vanc + rocephin at osh. was started on levophed 0.09, sedated with fent and midaz. given 5 l warmed ns. had r ij placed. ct torso performed in ed. family says: no allergies, full code, has ho right knee surgery and right hip surgery? labs notable for positive ua, inr 1.7, ptt 22, wbc 17, hct 45, plt 386. p 9.1, mg 4.4, ca 8.5. ck 450. na 169, k 5.4, cl 127, bicarrb 19, bun 255, cr 4.0, gluc 167. ag 23. trop 0.03. lacate 3.5. albumin 3.1, alt 34, ast 30, ap 78, 1, lipase 598. on arrival to the icu, pt is intubated, sedated, has numerous eschar ulcers on right side of body and forehead, not responsive, appears comfortable. review of systems: unable to obtain past medical history: "knee and hip replacement" records: atrial fibrillation oth screen -malign neoplasm of breast osteoporosis nos hypertension nos acute diastolic hrt failure rheumatoid arthritis mechanical loosening of prosthetic joint abn react-artif implant knee joint replacement status no proc/contraindication exam pre-operative nec painful respiration pain in thoracic spine fracture one rib-closed fracture, cause nos fx lumbar vertebra-close hip joint replacement status anemia nos diverticulosis colon (w/o ment of hemorrhage) chest pain nos joint pain-pelvis arthropathy nos-unspec joint pain-l/leg joint pain-shlder backache nos arthropathy nos-forearm malf int orthped dev/grf social history: hoarder, as per ems when finding patient family history: unable to obtain physical exam: admission physical exam: vitals: hr 155 in a fib, bp 100/82 on cmv vt 450, rr 14, fio2 50%, peep 5, peak pressure 19 platueu presure 17,, rr 19, 98% on vent general: somnolent, intubated, disheveled appearing, eschar ulcers all over right side of body heent: sclera anicteric, drr mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: anterior breath sounds without crackles cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: cool, mottled extremities, poor capillary refill discharge physical exam: general: alert and oriented x name, disheveled appearing, eschar ulcers all over right side of body heent: sclera anicteric, drr mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: anterior breath sounds without crackles cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly pertinent results: admission labs: 06:41am blood wbc-13.7* rbc-4.08* hgb-10.7* hct-37.0 mcv-91 mch-26.3* mchc-29.0* rdw-17.4* plt ct-317 02:35am blood wbc-16.7* rbc-4.61 hgb-12.2 hct-41.7 mcv-91 mch-26.4* mchc-29.2* rdw-17.3* plt ct-345 10:15pm blood wbc-17.4* rbc-5.15 hgb-13.9 hct-45.5 mcv-88 mch-27.0 mchc-30.6* rdw-17.3* plt ct-386 10:15pm blood neuts-95.5* lymphs-2.3* monos-2.0 eos-0 baso-0.1 02:35am blood pt-18.4* ptt-25.1 inr(pt)-1.7* 10:15pm blood pt-18.2* ptt-22.6* inr(pt)-1.7* 08:11pm blood glucose-97 urean-116* creat-2.1* na-156* k-4.8 cl-130* hco3-15* angap-16 12:24pm blood glucose-223* urean-132* creat-2.3* na-159* k-3.5 cl-131* hco3-14* angap-18 06:41am blood glucose-489* urean-169* creat-2.6* na-157* k-3.9 cl-128* hco3-12* angap-21* 02:35am blood glucose-130* urean-212* creat-3.0* na-171* k-4.2 cl-135* hco3-17* angap-23* 10:15pm blood glucose-167* urean-255* creat-4.0* na-169* k-5.4* cl-127* hco3-19* angap-28* 06:41am blood alt-24 ast-24 ld(ldh)-269* alkphos-54 totbili-0.6 02:35am blood amylase-172* 10:15pm blood alt-34 ast-30 ck(cpk)-450* alkphos-78 totbili-1.0 02:35am blood lipase-235* 10:15pm blood lipase-598* 10:15pm blood ctropnt-0.03* 08:11pm blood calcium-8.0* phos-3.9 mg-2.3 10:15pm blood albumin-3.1* calcium-8.5 phos-9.1* mg-4.4* 10:15pm blood osmolal-436* 02:35am blood tsh-0.75 08:11pm blood cortsol-45.6* 10:15pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:38pm blood type-art temp-37.9 rates-/21 peep-5 fio2-50 po2-139* pco2-24* ph-7.43 caltco2-16* base xs--5 intubat-intubated 03:28pm blood type-art temp-37.4 rates-/20 peep-10 fio2-50 po2-160* pco2-23* ph-7.41 caltco2-15* base xs--7 intubat-intubated vent-spontaneou 03:26am blood type-art rates-22/ tidal v-452 peep-5 po2-78* pco2-32* ph-7.32* caltco2-17* base xs--8 intubat-intubated vent-controlled 01:20am blood po2-315* pco2-33* ph-7.30* caltco2-17* base xs--8 08:38pm blood lactate-2.1* 03:28pm blood lactate-2.3* 03:26am blood lactate-2.6* 10:38pm blood lactate-3.5* 03:26am blood freeca-0.98* pertinent interval labs: 03:18am blood wbc-19.8* rbc-3.66* hgb-9.7* hct-32.1* mcv-88 mch-26.5* mchc-30.2* rdw-17.7* plt ct-220 02:44am blood wbc-6.2 rbc-3.40* hgb-9.1* hct-28.7* mcv-85 mch-26.9* mchc-31.9 rdw-17.9* plt ct-146* 03:15am blood glucose-144* urean-22* creat-0.6 na-147* k-3.7 cl-113* hco3-30 angap-8 02:35am blood glucose-130* urean-212* creat-3.0* na-171* k-4.2 cl-135* hco3-17* angap-23* 06:41am blood glucose-489* urean-169* creat-2.6* na-157* k-3.9 cl-128* hco3-12* angap-21* 12:24pm blood glucose-223* urean-132* creat-2.3* na-159* k-3.5 cl-131* hco3-14* angap-18 08:11pm blood glucose-97 urean-116* creat-2.1* na-156* k-4.8 cl-130* hco3-15* angap-16 03:34am blood glucose-141* urean-102* creat-1.9* na-160* k-4.4 cl-132* hco3-16* angap-16 11:52am blood glucose-235* urean-85* creat-1.7* na-155* k-3.8 cl-128* hco3-16* angap-15 09:00pm blood glucose-187* urean-63* creat-1.3* na-155* k-3.4 cl-128* hco3-17* angap-13 03:18am blood glucose-178* urean-52* creat-1.2* na-155* k-3.3 cl-127* hco3-17* angap-14 11:55am blood glucose-168* urean-42* creat-1.0 na-148* k-3.3 cl-121* hco3-19* angap-11 05:34pm blood glucose-259* urean-27* creat-0.7 na-147* k-3.9 cl-112* hco3-31 angap-8 04:06am blood glucose-100 urean-17 creat-0.5 na-142 k-3.7 cl-109* hco3-27 angap-10 02:57am blood alt-212* ast-246* ld(ldh)-657* ck(cpk)-125 alkphos-104 totbili-1.0 10:15pm blood lipase-598* 02:35am blood lipase-235* 03:15am blood lipase-22 10:15pm blood ctropnt-0.03* 02:45pm blood calcium-7.7* phos-4.7*# mg-1.9 03:46am blood vitb12-710 10:15pm blood osmolal-436* 02:35am blood tsh-0.75 08:11pm blood cortsol-45.6* 05:24am blood vanco-9.4* 10:15pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:28pm blood type-art temp-37.4 rates-/20 peep-10 fio2-50 po2-160* pco2-23* ph-7.41 caltco2-15* base xs--7 intubat-intubated vent-spontaneou 08:14am blood type-art rates-/21 tidal v-500 peep-5 fio2-40 po2-131* pco2-21* ph-7.50* caltco2-17* base xs--4 intubat-intubated vent-spontaneou 03:26am blood lactate-2.6* 03:28pm blood lactate-2.3* 08:38pm blood lactate-2.1* 03:50am blood lactate-1.5 09:08pm blood lactate-1.8 discharge labs: 02:53am blood wbc-2.9*# rbc-3.08* hgb-8.4* hct-26.0* mcv-85 mch-27.2 mchc-32.1 rdw-18.0* plt ct-128* 02:53am blood neuts-61.2 lymphs-26.1 monos-4.6 eos-7.3* baso-0.7 02:53am blood pt-13.5* inr(pt)-1.3* 02:53am blood glucose-121* urean-17 creat-0.5 na-138 k-3.7 cl-105 hco3-28 angap-9 02:44am blood alt-52* ast-22 ld(ldh)-344* alkphos-98 totbili-0.4 02:53am blood calcium-7.6* phos-1.5* mg-1.8 cxr (): impression: 1. no pneumonia. linear atelectasis better seen on ct. 2. endotracheal tube 3.9 cm above the carina. 3. right internal jugular catheter ends in the right atrium and could be pulled back 5 cm to place it in the mid to distal svc. ct abd/pelvis (): impression: 1. no pneumonia. 2. no acute process in the abdomen or pelvis. no evidence of traumatic injury. 3. multiple vertebral compression fractures in the thoracolumbar spine of unknown chronicity. sternal fracture, probably subacute-chronic given the callus formation. 4. right internal jugular catheter ends in the right atrium. 5. 5mm right middle lobe nodule. if patient has no risk factors for malignancy, this can be followed up with dedicated chest ct in 12 months. if pt has risk factors for malignancy (e.g. smoking history), dedicated chest ct is recommended in months. 6. fatty 2.1 cm lesion in left pelvis, likely post surgical fat necrosis or possibly dermoid in the left adnexa. suggest a follow up imaging study be obtained in 6 months to ensure stability - since visualization may be difficult with ultrasound given its location this could be performed with pelvic ct. ecg study date of 10:05:02 pm atrial fibrillation with a rapid ventricular response. non-specific st-t wave changes. no previous tracing available for comparison portable tte (complete) done at 11:41:34 am final the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. hip unilat min 2 views left port study date of 2:10 pm there is severe osteopenia, limiting the evaluation of the bony cortex. no definite fracture is seen. the patient is status post left hemiarthroplasty of the hip. there is no evidence of hardware loosening or failure. numerous surgical clips are seen within the lower left pelvis. impression: no fracture. cxr (): bilateral pleural effusions, large on the left and moderate on the right as well as mild pulmonary edema have progressed. cardiomegaly is severe and unchanged. mitral annulus calcification may indicate mitral regurgitation. no pneumothorax. cxr (): patient has had a history of recurrent episodes of pulmonary edema; today it is worse. there has been interval increase in cardiomegaly and pulmonary edema. bilateral pleural effusion is seen. lung volumes are stably low. right-sided picc catheter is seen terminating in the low svc. there is no pneumothorax. cxr (): again marked cardiomegaly is identified and rather advanced dens calcifications occupy the mitral ring area. the latter finding matches the previous torso ct identified cardiac changes which included marked enlargement of the left atrium. the pulmonary vasculature is somewhat congested, but not significantly more than it was on the preceding study. the same holds for the hazy density on the lung bases and particularly on the left side over the whole hemithorax compatible with pleural effusions layering the posterior pleural spaces as the patient is placed supine. no significant interval change can be identified. there is no pneumothorax. cxr () as compared to the previous radiograph, there is no relevant change. moderate cardiomegaly, mild-to-moderate bilateral pleural effusions, and subsequent areas of atelectasis. no evidence of newly occurred focal parenchymal opacities. unchanged course of the nasogastric tube. brief hospital course: brief hospital patient summary =================== 77 f found down x several days in hoarding environment admitted for pressure ulcers, hypernatremia, acute renal failure, ams, sirs. active issues =================== #hypovolemic versus septic shock secondary to dehydration/ skin ulcer infection with sodium 170 and bun 255, arf and anion-gap metabolic acidosis: patient admitted on extremely dehydrated, started on iv fluid resuscitation. patient intubated and norepinephrine pressors on for a day and phenylephrine on for a day. initial goal to decrease na slowly, 169->159 within 24 hrs. patient was 10l up after aggressive initial resuscitation and subsequent diuresis following extubation. on initial calculation, patient had 3l free water deficit. ck only 400 so less likely rhabdo. patient's urine output picked up with initial resuscitation and her sodium corrected quickly to the 150s. following extubation patient did continue to have difficulty maintain po intake and her sodium increased again following a low of 145. patient did endorse thirst but was still unable to maintain her fluid intake. she was seen by speech and swallow who recommended pureed solids, thin liquids and pills crushed in apple sauce and nutrition who recommended tube feeds if unable to maintain po intake. unfortunately, the patient was unable to tolerate po liquids or solids (pouching in her cheek), thus an ng tube was placed for tube feedings. #urinary tract infection (pseudomonas, no sensitivities): patient has been febrile starting . f/u sensitivities at laboratory. pt w/ indwelling foley, changed on after urine culture growth. no growth on blood cultures. on , re-initiated vanc/zosyn, and narrowed to zosyn only on . recommend 8 day course, to finish . .# malnutrition: pt on tube feeds at 50cc/hr continuously. tubefeeding: replete with fiber full strength; starting rate: 30 ml/hr; advance rate by 10 ml q4h goal rate: 50 ml/hr. residual check: q4h hold feeding for residual >= : 200 ml. flush w/ 50 ml water q6h. have been repleting electrolytes prn in setting of malnutrition. # acute encephalopathy, toxic metabolic: unclear origin although waxing and and likely delirium, w/out able to take pos, in icu, elderly. unclear baseline. also possible is medications vs initial hypernatremia vs infection vs pain vs effects of intubation/icu delirium. now much more alert and awake but still with significant deficits. recent tsh 0.75. b12 / rpr wnl. pt currently being treated for uti. continues waxing and course. keep up tube feeds. skin check qd. continuing to enforce sleep cycles, keep up in chair, re-orient prn. decreased fentanyl patch from 50mg to 37mg. #generalized pain: most likely secondary to extremely severe skin wounds. no acute fracture per radiology. patient has realized reasonable pain relief with liquid tylenol q6hrs prn, dilaudid 0.25-0.5 q3hrs prn, oxycodone 5-10mg q2hrs prn breakthrough pain, fentanyl patch 37mg q72 hrs. requires prn dosages prior to procedures, wound dressing changes, bed movements. #unstageable pressure ulcers contributing to sepsis/ hypotension above and causing pain: pt with tachycardia, hypothermia, leukocytosis, initially with bp 70s, lactate 3.5, ams, although no clear source of infection. would consider ulcers, aspiration pneumonia (not appreciated on chest ct and o2 sat has been fine prior to vent), uti, sinusitis. pancreatitis can also presents with several sirs criteria. skin cultures were remarkable for pseudomonas. patient treated with zosyn for 7 days (last day ) and vancomycin for 6 days, renally dosed. while in the icu, patient received tetanus vaccine. pain control in the icu was achieved with oxycodone (patient on vicodin at home) and iv fentanyl. on patient received 250 micrograms of fentanyl and was transitioned to a fentanyl patch 50 micrograms/hour. currently, pt is patient has realized reasonable pain relief with liquid tylenol q6hrs prn, dilaudid 0.25-0.5 q3hrs prn, oxycodone 5-10mg q2hrs prn breakthrough pain, fentanyl patch 37mg q72 hrs. daily dressing changes, and guidance from wound nurses # a fib: had been in rvr off and on throughout icu stay. was on dilt and metop at home, as well as warfarin. patient unable to take pos now. afib w/ rvr responsive to iv metoprolol. have continued ng tube placement for po medications. continue dilt 60mg qid po and metoprolol to 25 mg po tid. patient currently subtherapeutic on warfarin, have restarted warfarin 1mg qd. #pancytopenia: potentially from methotrexate administration last week. zosyn can cause but has been on before. would recommend getting cbc daily until counts start to rise. #transaminitis: stable to resolving. most likely reaction from previous methotrexate infusion vs. hypotension. have continued to trend. no e/o ruq tenderness. # ra: chronic. confirmed with dr. pcp about home medication listing and fact that neck pain is not regular ra distribution. would recommend not giving methotrexate as concern may have caused transaminitis and ? pancytopenia. continued 10mg prednisone daily transitional issues ==================== radiology incidental findings - 5mm right middle lobe nodule. if patient has no risk factors for malignancy, this can be followed up with dedicated chest ct in 12 months. if pt has risk factors for malignancy (e.g. smoking history), dedicated chest ct is recommended in months. - fatty 2.1 cm lesion in left pelvis, likely post surgical fat necrosis or possibly dermoid in the left adnexa. suggest a follow up imaging study be obtained in 6 months to ensure stability - since visualization may be difficult with ultrasound given its location this could be performed with pelvic ct. - trend lfts - pt treatment - rheumatology eval s/p recovery - methotrexate being held in setting of elevated lfts and ? pancytopenia -- would be wary of restarting - warfarin 1mg qd restarted - dr. - clear ra development, question upper vertebra. this physician has had extensive relationship with patient (more so than most of her relatives). dr. , patient would not want to be kept alive on a ventilator if not able to get off. she would not want to have cpr and would not want intubation unless reversable process, no defibrillation. - (nephew) - - , relationship: brother phone: - rdianship needed (unable to promote an individual on her own to hcp): court had appointed a ms. as the guardian, which should become official on tuesday. - daily dressing changes - cbc daily until counts trend up - call lab to f/u sensis on pseudomonas in urine disposition: ms. is being transferred to in ; the clinical nurse liaison is (). sw spoke with her brother re the transfer and provided him with the contact information for the facility. medications on admission: lasix 20mg daily dilt 240 daily warfarin 2.5 asdir metoprolol 25 mtx 2.5mg tab 7 tab 1x weekly prednisone 10mg daily () percoset 5/325 po q6h prn vicadin 5/500 q6h prn ca/vit d 350-125 daily discharge medications: see attached discharge disposition: extended care facility: northeast - discharge diagnosis: septic shock from pulmonary/skin source altered mental status, acute encephalopathy hypernatremia urinary tract infection malnutrition atrial fibrillation unstageable pressure ulcers discharge condition: serious discharge instructions: ms. , it has been a pleasure taking care of you. you are being transferred to in ; the clinical nurse liaison is (). social work spoke with your brother re the transfer and provided him with the contact information for the facility. followup instructions: you should follow-up with your primary care provider and any other pertinent specialists after you recover from the . procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube arterial catheterization insertion of (naso-)intestinal tube central venous catheter placement with guidance diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia unspecified protein-calorie malnutrition severe sepsis atrial fibrillation acute on chronic diastolic heart failure acute respiratory failure septic shock pressure ulcer, other site antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use rheumatoid arthritis accidents occurring in other specified places other encephalopathy hyperosmolality and/or hypernatremia pseudomonas infection in conditions classified elsewhere and of unspecified site nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] dysphagia, oropharyngeal phase generalized pain pressure ulcer, unstageable other pancytopenia 

Answer: The patient is high likely exposed to