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: ampicillin / dapsone / indinavir / cleocin / ceftriaxone attending: chief complaint: respiratory distress major surgical or invasive procedure: intubation arterial line central venous catheter history of present illness: 43 yo male with end stage aids (cd4 count 4, with viral load 91,500) complicated by , cmv retinitis, hiv cardiomyopathy with chf and ef 25%, pneumocystis carinii pna, pseudomonal pna, admitted with respiratory distress and diarrhea. pt went to his primary care physician 4 days prior to admission and started on empiric pneumocystis carinii pna treatment with bactrim/steroids. pt felt good over weekend- working in garden and then acutely worsened overnight. pt felt a lot worse today complaining of sob, crampy abdominal pain, and came to ed for evaluation. in ed, the patient had cxr which showed bilateral patchy opacities and abg was 7.20/22/105 but felt to be relatively stable. pt was initially hypotensive but responded to normal saline fluid boluses. pt found to have inr of 5.2 so transferred to the medical icu (east). sepsis protocol was not activated at that time. currently, pt complaining of sob and breathing still very labored. +diarrhea, fever & chills. mild abdominal pain. denies cp, n/v, urinary symptoms. past medical history: 1. hiv/adis- cd4 count 4 and vl 91,500 -c/p pcp (), azt toxicity, cmv retinitis, mac, esophageal candidiasis 2. pseudomonal pna 3. cardiomyopathy hiv with ef 25-30% 4. hepatitis c 5. hypothyroidism 6. anemia 7. cervical disk disease 8. r foot drop 9. depression 10. chronic pain 11. bcc 12. scc 13. chronic diarrhea 14. cmv 15. raynaud's phenomenon social history: lives in with partner, , who he has spent the last 10 years with, and 2 dogs. no etoh or tobacco use. no ivda. is his health care proxy. one brother in , and one brother in . family history: nc per patient physical exam: t 99.8 hr 140-150 bp 93/43 rr 20 o2sat 90-92% on a 100%nrb gen: frail, cachectic, nad, aaox3, speaking in word sentences. patient using accessory msucles of respiration. heent: perrl, eomi, mmm, op clear- no thrush visible. cv: tachycardic and without murmurs, rubs or gallops. lungs: +breath sounds bilaterally, no crackles, no wheezes abd: soft, nt, slightly distended, +bs, rectal deferred ext: w/wp, no edema, 2+ dp pulses; erythema over joints in hands neuro: moves all 4 extremities pertinent results: 08:19pm type- o2-100 po2-38* pco2-48* ph-7.04* total co2-14* base xs--19 aado2-644 req o2-100 intubated-not intuba comments-non-rebrea 08:22pm gran ct-280* 08:22pm fibrinoge-687*# d-dimer-221 08:22pm pt-26.9* ptt-44.2* inr(pt)-5.3 08:22pm crp-140.2* 08:22pm cortisol-29.1* 08:22pm lipase-1227* 08:22pm alt(sgpt)-36 ast(sgot)-42* ld(ldh)-390* alk phos-236* amylase-515* tot bili-0.6 08:22pm wbc-0.6*# rbc-3.84* hgb-10.4* hct-33.9* mcv-88 mch-27.2 mchc-30.8* rdw-16.7* . echo ef<25% conclusions: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is severe global left ventricular hypokinesis. overall left ventricular systolic function is severely depressed. the right ventricular cavity is mildly dilated. right ventricular systolic function appears depressed. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the prior study (tape reviewed) of , left ventricular systolic function appears slightly more depressed. the right ventricle is now mildly dilated and free wall motion may be more depressed. . cxr (): impression: rapid development of multifocal parenchymal opacities consistent with multifocal pneumonia cxr (- 2:30am): multiple regions of consolidation have progressed substantially consistent with bacterial pneumonia. interval increase in the heart size and mild pulmonary edema suggest cardiac decompensation. stomach is markedly distended with air. there is no large pleural effusion, though a small volume of right pleural fluid may be present. no pneumothorax. cxr (- 7am): two focal pulmonary consolidation has progressed substantially consistent with worsening pneumonia. there is a small component of pulmonary edema and new small right pleural effusion. et tube and left subclavian line are in standard placements. no pneumothorax cxr endotracheal tube is 5 cm above carina. left subclavian cv line is in proximal svc. ng tube is in stomach. no pneumothorax. there are diffuse bilateral patchy pulmonary opacities, unchanged since the prior film of , consistent with multifocal pneumonia. cxr impression: persistent focal left lower lobe opacity, as well as bilateral patchy alveolar densities. the overall appearance is essentially unchanged. note: all subsequent cxr until pt's death on were unchanged. he had persistent bilateral patchy alveolar densities, consistent with multifocal pneumonia. . ct abd/pel impression: 1. increased consolidation seen in the visualized lung bases with larger bilateral pleural effusions. 2. increased anasarca and ascites. 3. continuing evidence of colitis, with improvement in the proximal colon, but more distally unchanged. . 1:20 pm immunology (cmv) **final report ** cmv viral load (final ): 703 copies/ml. performed by pcr. detection range: 600 - 100,000 copies/ml. for research use only.. not for use in diagnostic procedures. this test has been validated by the microbiology laboratory at . . 3:07 am immunology (cmv) **final report ** cmv viral load (final ): 807 copies/ml. performed by pcr. detection range: 600 - 100,000 copies/ml. for research use only.. not for use in diagnostic procedures. this test has been validated by the microbiology laboratory at . reported by phone to dr 1040. . 1:47 pm sputum site: endotracheal source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 8 s ciprofloxacin--------- =>4 r gentamicin------------ 4 s imipenem-------------- =>8 i meropenem------------- =>16 r piperacillin---------- 32 s piperacillin/tazo----- 64 s tobramycin------------ <=1 s fungal culture (preliminary): aspergillus fumigatus. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): . 4:54 pm stool consistency: formed **final report ** ova + parasites (final ): no ova and parasites seen. . 10:53 am stool consistency: soft source: stool. microsporidia stain (final ): no microsporidium seen. cyclospora stain (final ): no cyclospora seen. fecal culture (final ): no enteric gram negative rods found. no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. o&p macroscopic exam - worm (final ): test cancelled, patient credited. test will be ordered if worm is present. clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative. viral culture (preliminary): no virus isolated so far. . 11:08 pm stool consistency: loose clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative . 4:18 am stool consistency: watery source: stool. das requested by dr., () . microsporidia stain (final ): no microsporidium seen. cyclospora stain (final ): no cyclospora seen. fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. acid fast culture (pending): acid fast smear (final ): no acid fast bacilli seen on concentrated smear. . 4:00 pm bronchoalveolar lavage gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. modified acid-fast stain for nocardia (final ): test cancelled by laboratory due to lack of branching gram positive rods in the gram stain. gram stain is an equally sensitive means of detecting nocardia in a primary specimen. culture may be a more sensitive means of detecting nocardia and should be considered. patient credited. respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. sparse growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- r ciprofloxacin--------- =>4 r gentamicin------------ 4 s imipenem-------------- 2 s meropenem------------- 2 s piperacillin---------- 32 s piperacillin/tazo----- 64 s tobramycin------------ <=1 s legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): test cancelled by laboratory. patient credited. this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). immunofluorescent test for pneumocystis carinii (final ): pneumocystis carinii not seen. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. . brief hospital course: a/p: 43 yo male with end-stage aids admitted with respiratory distress, intubated, found to have e. coli bacteremia, multifocal pna and later ards, and diarrhea, presumed clostridium difficile colitis based on ct scan, however repeated cultures negative, and improved on flagyl. . 1. the pt initially presented in acute sepsis, with e. coli in bottles blood cultures on admission, aztreonam-sensitive. the pt developed hypotension with well-perfused extremities and suggestive for distributive/septic shock, and was given pressors and agressive fluid resuscitation after adequate venous access was established. his map was maintained at >60, and cvp >16. eventually, his pressors were titrated off and he was fluid bolused to maintain his map. throughout his stay, he had good glycemic control, titrated with insulin gtt for fsbs 80-120. initially with an elevated lactate, which trending down. his cortstim was positive for adrenal insufficiency, and he finished a course of stress dose steroids. . a. multifocal pna: his bronchioloalveolar lavage was consistent with pseudomonas (2 species found, aztreonam sensitive), pcp/legionella/afb negative by bal. he was histoplasma/aspergillus negative. he was begun on iv aztreonam. ddx also included fungal pna, and pt was covered with caspofungin initially as well, until repeated sputum, blood, and bal cx failed to reveal fungal etiology. he was initally covered with vancomycin iv as well, which was discontinued after repeated cultures failed to reveal mrsa. eventually, however, his cultures revealed his pseudomonas had become ceftazidime-resistant (and a proportion of pts with ceftaz-resistant pseudomonas become aztreonam resistant as well), so iv aztreo was changed to iv meropenem. the meropenem was started on . repeat endotracheal sputum cultures two days prior to his death demonstrated his pseudomonas had become iv meropenem resistant, but sensitive to tobramycin and gentamycin. he was made measures only, however, so iv tobramycin or gentamycin was not started. he was also empirically treated for pcp pna with atovaquone, which was later discontinued, as the pt was developing increasing amylase and lipase, and 8% of pts on atovaquone can develop amylase elevations and pancreatitis. his pna did not improve and he developed progressive pulmonary disease consistent with ards. he was maintained on ards net tidal volumes (450-470), and he required a high minute ventilation, with plateau of 26 and peep that remained around 15. he had a large amount of dead-space in his lungs. he was unable to be weaned from the vent, and remained on assist control until extubation and subsequent expiration after being made cmo. . b. infectious colitis: diarrhea improved over the course of his stay. it was thought that e coli may have seeded the blood, but was felt not likely to be the causative in his infectious colitis, which is most likely clostridium difficile. repeated stool studies have been negative thus far. in this particular pt, the differential diagnosis is broad and includes cmv, hsv, cryptosporidia, microsporidia, histo/crypto, ecoli, mac, tuberculosis, salmonella, shigella, cdiff, parasitic. diffuse colitis on ct, thought to be likely infectious. repeated cdiff cultures were sent and were all negative. at the time of his death, cdiff toxin b was still pending at the state lab. he was empirically treated at admission with iv flagyl, which was later transitioned to po flagyl. he remained on po flagyl until expiration. gi consult was obtained, and followed the pt throughout his stay. cmv titers were drawn, revealing a level of 807, and our consultants recommended starting iv gancyclovir at induction doses. infectious disease consultation was also obtained, with resent stool cultures failing to reveal an etiology for his continued diarrhea. he was initially begun on clarithromycin on admission for prophylaxis, however, this was subsequently discontinued, as a side effect of clarithromycin is thrombocytopenia, and our pt was persistently thrombocytopenic. . 2. thrombocytopenia: the pt required daily transfusions of platelets. it was felt likely multiple factors including sepsis leading to marrow suppression and medication-induced. also considered hiv-induced itp. very acute drop in platelets, concerning for dic. however, there is no evidence of oozing or major bleeding, and dic labs were repeatedly negative. he was hit ab negative. we reviewed all medications to look for medication-induced thrombocytopenia; h/o bactrim in past not on it now; no haart therapy now; on vancomycin with scattered case reports that vancomycin can cause decr plt; with plt drop prior to starting aztreonam. aztreonam had 1 case report of causing thrombocytopenia. caspofungin can also cause. spoke with id fellow and decided to d/c caspo and vanco. d/c'd aztreonam and clarithromycin as well. hematology/oncology was consulted regarding the aforementioned issues. he was transfused for plt level<10. . 3. anemia: unclear source, possible marrow suppression from sepsis. peripheral blood smear negative for schistocytes and helmet cells. hemolysis labs negative. no evidence of bleeding clinically or on ct. his hct remained stable, and his b12 and folate levels were normal. . 4. chf with hiv cardiomyopathy- the pt demonstrated evidence of volume overload. once his arf resolved, and his cr returned to baseline, the pt was diuresed with iv lasix, with goal output -1-2 l per day. . 5. acute renal failure- resolved. baseline cr 0.9. currenlty etiology of renal failure is most likely pre-renal leading to atn, with high fena on admission. the pt had good , not oliguric atn. we thought less likely not hiv nephropathy as no proteinuria. normal kidneys seen on ct abd/pel. received mucomyst peri-ct, as well as hydration. . 6. direct bili elevation with elevated amylase/lipase. during his admission, the pt developed increasing total bilirubin, with increased direct bilirubin specifically, as well as rising amylase, lipase, and lfts. this was a complicated picture, as no pancreatits was seen on ct abd, and two ruq ultrasounds failed to reveal an obstruction as the cause of his hyperbilirubinemia. a surgical consult was also obtained, however, they did not feel that surgical intervention was warranted in this pt. all medications known to cause elevations in amylase and lipase and pancreatitis were discontinued. medication induced cholestasis was considered, as well as acalculous cholecystitis. however, his ruq ultrasound failed to reveal sludging and extensive wall thickening. the pt was a poor surgical candidate. eventually, with medication discontinuation and changes being made, his lfts, amylase, lipase, and total bilirubin trended down. the etiology of these aberrations are still yet to be ascertained or fully appreciated. . 7. neutropenia: resolved over the course of his stay. it was presumably from infection/sepsis with suppression of bone marrow. also thought it could be something chronic b/c on neupogen/epogen and may be med related such as valtrex or bactrim. the pt was placed on neutropenic precautions and his wbc ct improved. he was started on neupogen, with good response, and this medication was later discontinued. . 8. high inr- was 5 on admission, then trended down to a normal range. with an unnclear etiology, given that dic labs were negative. the pt was on several antibiotics as outpatient, could be loss of bacterial flora that make vitamin k. his coags were followed , and he was monitored closely for signs of bleeding. he received vitamin k. heme/onc was consulting on this case. . 9. aids: holding haart therapy at present. his pcp prophylaxis and prophylaxis was discontinued because of thrombocytopenia and medication-induced possible side effects (increased amylase, pancreatitis with atovaquone). this was discussed with the infectious disease consult before discontinuing, and it was felt that there was no evidence to suggest his pna or diarrhea was secondary to pcp or . it was decided that the risk of continuing these meds with his high amylase and lipase, as well as extremely low plt outweighed the benefit. . 10. code status- after a prolonged hospital course, without clear signs of improvement, it was decided by swann, the health care proxy to be made measures only. he was dnr throughout his stay. he was intubated during his stay, until his death, which was secondary to respiratory failure after extubation and withdrawal of care. he was made comfortable with fentanyl at the time of death to minimize the sensation of shortness of breath/dyspnea. his family was at his side when he was extubated and expired. medications on admission: 1. testosterone 5 mg/24 hr patch 24hr sig: two (2) patch 24hr transdermal daily (daily). 2. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). 3. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). 4. clarithromycin 500 mg tablet sig: one (1) tablet po daily (daily). 5. ethambutol hcl 400 mg tablet sig: two (2) tablet po daily (daily). 6. fentanyl 75 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 7. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. lorazepam 1 mg tablet sig: two (2) tablet po hs (at bedtime). 10. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 11. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 12. oxycodone hcl 40 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q12h (every 12 hours). 13. mirtazapine 30 mg tablet sig: one (1) tablet po hs (at bedtime). 14. atazanavir sulfate 200 mg capsule sig: two (2) capsule po daily (daily). 15. methylphenidate hcl 10 mg tablet sig: one (1) tablet po daily (daily) as needed. 16. sodium bicarbonate 650 mg tablet sig: one (1) tablet po bid (2 times a day). 17. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 18. valganciclovir hcl 450 mg tablet sig: two (2) tablet po daily (daily). 19. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po daily (daily). 20. buspirone hcl 15 mg tablet sig: 0.5 tablet po bid (2 times a day). 21. cyclobenzaprine hcl 10 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. 22. lamivudine 150 mg tablet sig: one (1) tablet po bid (2 times a day). 23. levothyroxine sodium 150 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 24. abacavir sulfate 300 mg tablet sig: one (1) tablet po bid (2 times a day). 25. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed. 26. loperamide hcl 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. 27. filgrastim 480 mcg/1.6 ml solution sig: one y (150) mcg injection q mon, thurs (). discharge disposition: expired discharge diagnosis: 1. sepsis 2. escherichia coli bacteremia 3. hypoxemic respiratory failure secondary to multifocal pneumonia 4. infectious colitis with diarrhea 5. thrombocytopenia 6. anemia 7. end-stage aids 8. hiv cardiomyopathy 9. acute renal failure discharge condition: expired on , autopsy consent obtained md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus transfusion of packed cells transfusion of other serum transfusion of platelets diagnoses: other primary cardiomyopathies acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma severe sepsis human immunodeficiency virus [hiv] disease acute and chronic respiratory failure pneumonia due to pseudomonas septic shock intestinal infection due to clostridium difficile septicemia due to escherichia coli [e. coli] other and unspecified coagulation defects 

Answer: The patient is high likely exposed to