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: tagamet / ditropan / penicillins / lisinopril attending: chief complaint: altered mental status major surgical or invasive procedure: intubation, right subclavian central line, picc line placement history of present illness: 66 yo m with pmh of dm2, cri, recent subdural hematomas and bacteremia who presents from rehab with altered mental status. per the report from the rehab, at baseline he desats with activity, requiring 3-6l o2 to maintain o2 sats 88-92% and is a chronic co2 retainer. he was given iv lasix and was refusing bipap. given he was more disoriented he was brought to the ed. of note, his wife says that he received a blood transfusion on and has been more confused since that time. . in addition, in he was hospitalized for a fall and subsequent right subdural hematoma. this was complicated by a strep bovis endocarditis which was treated with 6 week of ceftriaxone. shortly after stopping the antibiotics he developed line sepsis from the picc which grew out mrsa and enteroccus. the tip was removed and he was treated with vancomycin given his penicillin allergy from until . . in the ed, his initial vital signs were t 98.1 hr 92 bp 118/78 rr28 94% 2l nc. temp rose to 101.8. he was oriented x1 or 2 and complained of abdominal pain intermittently. was given combivent neb and became more lethargic. surgery was consulted for ? ischemic bowel given is abdominal tenderness. lactate was normal though and ct scan was ordered. his blood pressure then dropped to systolic 64/48s and he was given 3l ivf, cvl was placed and levophed was started. he was intubated for airway protection given his altered mental status, but per report was not in any respiratory distress. he was given etomodate and succ, ativan. he had a ct torso looking for a source of infection. the only acute finding was a right pericardial effusion and right pleural effusion. he was given vancomycin and zosyn for empiric coverage. past medical history: -morbid obesity -dm type 2 poorly controlled with complications -chronic renal insufficiency -htn -reactive airways disease -asbestosis -gerd -parkinson's disease -detrusor instability -gout -hypothyroidism -aortic stenosis, valve area 0.9cm2, peak gradient 24, median gradient 48 -anemia -h/o nephrolithiasis -fall w/ r subdural hematoma, s/p strep bovis bacteremia and 6 wks ceftriaxone, developed bacteria after completion of tx with mrsa and enterococcus. line removed, tx with vanco then d/c'd. neg cx 3 consecutive days. - febrile, blood cxs + enterococcus, to pcn and vanc. got vancomycin due to pcn allergy. social history: no alcohol or tobacco use, currently resides at rehabilitation center, formerly owned pizzaria restuarants family history: non-contributory physical exam: vitals: afebrile bp 140/69, hr 83, 100% o2 sat. cvp 15, ac 650/18 peep 5, fio2 0.5, fs 132 general: morbidly obese, intubated and sedated. opens eyes to voice but does not follow commands heent: anicteric sclera, non-injected conjunctiva, pupils about 3mm and symmetric but sluggish, dry mm cv: rrr 3/6 sem heard best at the usb lungs: expiratory wheeze bilaterally, course breath sounds. mild crackles abdomen: obese, umbilical hernia reducible. +bs, soft, seems non-tender ext: trace bilateral edema, dp and pt pulses are strong and symmetric, bilateral upper extremity tremor with cogwheel rigidity neuro: opens eyes to voice. not following commands. moving all extremities. toes are down going bilaterally pertinent results: admission labs: wbc-10.9# rbc-3.14*# hgb-8.2*# hct-26.1*# mcv-83 mch-26.0* mchc-31.2 rdw-15.1 plt ct-313# neuts-87.8* lymphs-8.1* monos-3.4 eos-0.6 baso-0.1 pt-17.0* ptt-35.8* inr(pt)-1.5* glucose-68* urean-40* creat-2.3* na-140 k-3.7 cl-96 hco3-35* alt-17 ast-64* ck(cpk)-32* alkphos-105 totbili-0.6 albumin-3.1* -art rates-/22 tidal v-650 peep-5 fio2-100 po2-382* pco2-44 ph-7.49* caltco2-34* base xs-10 aado2-311 req o2-56 -assist/con intubat-intubated lactate-0.8 . additional labs: 01:23am blood %hba1c-6.5* 01:23am blood triglyc-169* hdl-15 chol/hd-7.1 ldlcalc-58 09:11pm blood tsh-9.2* 11:12pm blood cortsol-29.1* 09:11pm blood cortsol-13.6 12:22pm blood lipase-13 . studies: ekg: sinus rhythm. non-specific intraventricular conduction delay. non-specific st-t wave abnormalities. compared to the previous tracing of no change in comparable leads. . cxr - impression: limited exam due to low inspiratory effort. evaluation for new focal consolidation is limited, and a dedicated pa and lateral view of the chest is recommended. alternatively, ct can be performed for further evaluation. asbestos-related pleural disease. . ct head without contrast - impression: 1. no hemorrhage or edema. 2. chronic small vessel ischemic disease. 3. age-related involutional change. . central line placement - impression: relatively stable x-ray examination with possibility of added volume imbalance and overload. the central line has been introduced with no pneumothorax. distal tip at adequate position. support tubes as above. . ct abdomen & pelvis without contrast - impression: 1. new right pleural effusion and pericardial effusion. 2. possible cholelithiasis, but no evidence of cholecystitis. 3. bilateral atrophic kidneys. 4. no evidence of diverticulitis. . pleural fluid cytology: negative for malignant cells. scattered mesothelial cells present singly and abundant lymphocytes. . tee - no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is a moderate-sized (1.1 x 0.9 cm) nonmobile density on the right cusp of the aortic valve associated with partial cusp prolapse. the bulk of the echodensity is likely an old/healed vegetation, although a more acute superimposed valvular infection cannot be excluded on the basis of echocardiography alone. there is an associated eccentric, anteriorly-directed jet of moderate (2+) aortic regurgitation. there is mild aortic valve stenosis, with a valve area by planimetry of 1.6cm2. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. the estimated pulmonary artery systolic pressure is normal. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: likely aortic valve endocarditis, without evidence of an abscess or involvement of other valves. moderate aortic regurgitation. mild aortic stenosis. . bilateral upper extremity veins - impression: no evidence of dvt in either the right or left upper extremity. . mr , mra brain without contrast - impression: 1. focal area of slow diffusion in the left frontal lobe consistent with an area of acute infarction secondary to proximal emboli. 2. chronic small vessel ischemic disease. . mr c, t, & l spine - impression: 1. no evidence for abscess, spinal cord compression, or other spinal cord abnormality. 2. multilevel degenerative joint disease. disc protrusion at the level of t8-t9, and disc bulges at the level of l3-l4, and l4-l5. . bilateral lower extremity veins - impression: no lower extremity dvt. . carotid ultrasound - impression: 1. normal right carotid ultrasound with 0% stenosis. 2. minimal echogenic plaque within the left proximal internal carotid artery with normal peak systolic velocities consistent with less than 40% stenosis. cxr - impression: picc line at svc-ra junction, decreasing effusions. tte echo - the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the septum. the remaining segments contract normally (lvef = 50 %).right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. a vegetation is suggested but cannot be confirmed due to suboptimal image quality. there is moderate to severe aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. significant pulmonic regurgitation is seen. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the septal wall motion abnormality is new, the aortic valve morphology is more deformed, and the severity of both aortic stenosis and aortic regurgitation has increased. cxr - since yesterday, the patient was extubated and the nasogastric tube is removed. left picc still ends in unchanged position. interstitial edema decreased. heterogeneous opacities on the right slightly decreased, back to baseline from . small bilateral pleural effusions are unchanged. moderate cardiomegaly and vascular engorgement are stable. bilateral calcified plaques are also unchanged. brief hospital course: 66 yo m with pmh of dm2, cri, recent subdural hematomas and bacteremia who presents from rehab with altered mental status and fevers. # pneumonia/failure to wean: the patient was initially intubated for airway protection but his course was complicated by acineobater pneumonia and pulmonary edema secondary to volume overload required for fluid resuscitation in the setting of sepsis. the patient may also have some muscular weakness due to his prolonged illness. weaning from the ventillator was also complicated by copious secretions. the infectious disease service was consulted and recommended that for his acinobacter pneumonia he should be treated with tobramcyin and unasyn for a 14 day course to end . his tobramycin dose was gradually increased based on checking trobra serum levels. he was also given lasix boluses to help diurese some of the extra fluid and was on a lasix gtt for the last several days of his icu stay. he has been d/c'd on 40mg of lasix which is new for him, so his bp and cr should be followed closely; lasix dose - continue standing atrovent with prn albuterol. # endocarditis with ar: the id service was consulted and recommended that the patient receive a 6 week course of vancomycin (to end ) based on a positive blood culture for vancomycin sensitive enterococcus from at an osh (first negative blood culture on ). ct surgery was consulted during the middle of his icu stay and felt that aortic valve replacement was not indicated at this time. given the increased severity of aortic regurgitation noted on his echo, he will likely need to be reconsidered for aortic valve replacement when his condition has improved. patient should have colonoscopy to r/o underlying colon ca in the setting of strep bovis endocarditis. - he is to follow up with ct surgery, dr. , on . # echo with focal wall motion abnormalities (): these are new from prior echo (tee on ) although per cardiology the former was a poor study. these findings are likely ischemic in origin but it is unknown exactly when this change occurred. the patient was already on aspirin. he was started on a low dose statin and beta-blocker for cad after a likely nstemi based on these findings but we held until we see how his blood pressure does with the b-blocker. he had a fasting cholesterol panel earlier during his hospitalization with an ldl of 58. - can be added as indicated at rehab facility per discretion of rehab md based on creatinine and blood pressure. # cva: likely embolic stroke on mri, either from endocarditis, or atheroembolic. u/s of carotids was negative. the patient was evaluated by neurology while he was still intubated and recommended treating with aspirin but not otherwise anticoagulating. they did not feel that the stroke would contribute to mental status while he was intubated but have not otherwise weighed in since he had been extubated. he does not have any focal motor deficits. # altered mental status: likely secondary to infection and sedation while on the ventillator. head ct and mri do not explain ams per neurology. his mental status slowly improved during his icu stay, however, he continued to be somewhat confused and disoriented on discharge. # acute on chronic renal insufficiency stage 4: on admission the patient's creatinine was elevated to 2.3. his baseline was 1.3-1.4 earlier this year. his creatinine improved to a new baseline of 1.5 - 1.6 during his admission. he was continued on calcitriol and medications, including antibiotics, were renally dosed. for the 2 days before extubation and 2 days post-extubation mr was getting lasix boluses and then a lasix drip. he was started on 40 mg lasix po bid at discharge and should have his cr followed closely; as above, lasix can be - we continued his calcitriol 0.25 mcg daily. # hypertension: losartan and metoprolol were initially held due to sepsis and hypotension. metoprolol was restarted at a lower dose for cad. losartan was held due to continued low blood pressures while the patient was being diuresed. consider re-initiation of once bp stabilized on beta blocker. # type 2 diabetes mellitus: the patient was placed on an insulin sliding scale with regular insulin and q6h finger sticks while he was on tube feeds. # hypothyroidism: the patient's was continued on levothyroxine per his home dose. # hypotension: the patient had an episode of hypotension w/sbps down to 70??????s in the morning of . pressures improved with ns and 2u of prbcs. the patient was started on levophed but developed a run of ventricular tachycardia. levophed was changed to neosynephrine, which patient tolerated much better. the most likely etiology was septic shock. cardiac enzymes were negative. cxr was without pneumothorax. cta was not performed to r/o pe, but was felt to be unlikely given the patient's improvement. pressors were stopped later in the evening of and his blood pressure returned to . # parkinsons disease: carbidopa/levodopa and requip were continued per the patient's home regimen. # anemia: the patient has a history of chronic anemia for the last few months since his illness began. his anemia is likely related to chronic illness and iron deficiency (one report of colonic polyps removed). his hematocrit had returned to baseline following a transfusion a few days prior to admission. * prophylaxis: patient discharged on sc heparin and ppi. bowel meds prn. medications on admission: actos 15 mg daily calcitriol 0.25 mcg daily carbidopa-levodopa 50-200 5x/day cyanocobalamin mcg daily glipizide 5 mg qday prilosec 40 mg daily requip 3 mg qid synthroid 87.5 mcg daily heparin sc tid levofloxacin 250mg qday arinesp 0.1 mg qtuesday singular 10mg qday zinc sulfate 250mg po qday simethecone prn metoprolol 25mg po bid losartan 100mg po qday kcl 20 meq qday aspirin 325mg po qday iron 300mg po bid colace 100mg po bid senna 2 tabs daily bisacodyl prn combivent mdi prn fluticasone 1 puff duoneb prn tylenol prn regular insulin 151-200 give 2u, every 50 of blood sugar increase 2 u miconazole powder daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 3. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 4. carbidopa-levodopa 25-100 mg tablet : two (2) tablet po 5x/day (5 times a day). 5. cyanocobalamin 500 mcg tablet : four (4) tablet po daily (daily). 6. ropinirole 1 mg tablet : three (3) tablet po qid (4 times a day). 7. levothyroxine 25 mcg tablet : 3.5 tablets po daily (daily). 8. aspirin 325 mg tablet : one (1) tablet po daily (daily). 9. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily). 10. albuterol 90 mcg/actuation aerosol : four (4) puff inhalation q4h (every 4 hours) as needed for wheezing. 11. ipratropium bromide 17 mcg/actuation aerosol : four (4) puff inhalation qid (4 times a day). 12. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for fever. 13. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed. 14. pramoxine-mineral oil-zinc 1-12.5 % ointment : one (1) appl rectal (2 times a day) as needed for hemorrhoids. 15. metoprolol tartrate 25 mg tablet : one (1) tablet po bid (2 times a day): hold for sbp <100, hr < 50. 16. atorvastatin 10 mg tablet : one (1) tablet po daily (daily). 17. vancomycin 1000 mg iv q 24h for 6 week course, last date 18. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 19. insulin regular human 100 unit/ml solution : as directed injection qachs. 20. multivitamins with minerals capsule : one (1) tablet po daily (daily). 21. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 22. tobramycin sulfate 60 mg/6 ml solution : three hundred (300) mg intravenous q48h: last dose 11/27. 23. unasyn 3 gram piggyback : three (3) g intravenous every six (6) hours: last day . 24. lasix 40 mg tablet : one (1) tablet po twice a day. tablet(s) 25. outpatient lab work please draw liver function tests, bun, creatinine, vancomycin trough weekly and fax results to id physician . 26. calcitriol 0.25 mcg capsule : one (1) capsule po once a day. 27. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr once a day. 28. neutra-phos : one (1) packet three times a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnoses: 1. acinobacter pneumonia 2. endocarditis with aortic regurgitation 3. embolic cerebrovascular accident (cva) 4. acute on chronic renal insufficiency 5. altered mental status secondary diagnoses: 1. diabetes mellitus, type 2 2. hypothyroidism 3. parkinson's disease 4. hypertension 5. coronary artery disease discharge condition: stable, afebrile, satting well on a 40% face tent, sbp 100s-180s discharge instructions: you were admitted to the hospital because of altered mental status and a decrease in your oxygen level. you were found to have a pneumonia and were treated with antibiotics. you were placed on a ventillator to help support your breathing as a result of the pneumonia and the iv fluids that you received to support your blood pressure. you also have an infection on your heart valves which is being treated with antibiotics. please call your doctor or return to the emergency room should you develop any of the following symptoms: chest pain, fevers, difficulty breathing, altered mental status, or any other concerns. followup instructions: you should follow-up with your primary care physician, . , within two weeks of discharge from rehab. call to make this appointment. please discuss colorectal cancer screening with dr. . please come to clinic to see dr. on friday, . call his clinic at ( to confirm the time of this appointment. please keep this other already-scheduled appointment. provider: , md phone: date/time: 1:30 procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances thoracentesis transfusion of packed cells diagnoses: other iatrogenic hypotension anemia of other chronic disease esophageal reflux pneumonia due to other gram-negative bacteria acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia severe sepsis unspecified acquired hypothyroidism chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified asthma, unspecified type, unspecified aortic valve disorders paroxysmal ventricular tachycardia paralysis agitans acute respiratory failure alkalosis long-term (current) use of insulin septic shock morbid obesity iron deficiency anemia, unspecified calculus of gallbladder without mention of cholecystitis, without mention of obstruction acute and subacute bacterial endocarditis hypoxemia carrier or suspected carrier of methicillin resistant staphylococcus aureus cerebral embolism with cerebral infarction ventilator associated pneumonia acute on chronic systolic heart failure asbestosis umbilical hernia without mention of obstruction or gangrene other functional disorder of bladder other specified forms of effusion, except tuberculous 

Answer: The patient is high likely exposed to