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: history of present illness: this is a year old russian- speaking gentleman with recent admissions for multilobar pneumonia, recently discharged from on , now being readmitted for hypotension presumed to be septic. the patient has had three recent admits to with a question of multilobar pneumonia for which he has grown out stenotrophomonas in his sputum which has been ruled out for afb on multiple occasions due to a right upper lobe cavitary lesion. of note, afb smears were negative as well as bal. he was transferred to on for further management and here he was started on a ten day course of vancomycin/meropenem for a cavitary pneumonia although sputum cultures were largely negative. his course was complicated by a copd flare of which he was treated with a prednisone taper and a mild episode of chf after fluid resuscitation and also c. diff. colitis for which he was treated with flagyl. per reports, he had been doing well at but had remained on 4 liters nasal cannula since his recent discharge from . he has had mild increased coughing and sputum production and actually had been ambulating with pt and taking good po's. on the day of admission, he developed some mild lightheadedness and was noted to have hypotension with systolic blood pressures in the 60's to 70's, not responsive to 1500 cc of iv fluid. he was given vancomycin, gentamicin and bactrim at and then transferred to the emergency department. in the emergency department, the patient was afebrile. the blood pressure was 78/40 with an initial lactate of 4.8 and he was then treated per sepsis protocol. he received an additional three liters of iv fluids, received decadron and also added clindamycin. an ij was placed with cvp initially at 215 and a mixed venous o2 sat monitor was placed and were showing sats in the mid 70's. he was placed on 100 percent nonrebreather with saturations at 91 percent on 6 liters and he was stable and transferred to the icu. currently, he denies any shortness of breath other than notes some mild productive cough with some green sputum. he also notes some pleuritic chest pain. he has no abdominal pain, diarrhea or dysuria. past medical history: cad, status post cabg three years ago, unclear of results of anatomy of cabg and also reports having a cath in with also unknown results. chf, the last ef 40 percent on . hypertension. status post cva. hypothyroidism. anemia. status post prostate surgery. medications on transfer: albuterol nebs qid, aspirin 81 mg qd, lipitor 10 mg qhs, advair 500/50 diskus one puff q12h, folate qd, humibid long acting 1200 mg po q12h, heparin 500 units subcu q12h, atrovent nebs, iron sulfate 325 mg , bactrim tabs one q12h on the 18th, vancomycin 250 mg q6h, vancomycin 1 gm given on the 18th, prevacid 30 mg qd, synthroid 75 mcg qd, lopressor 25 mg , prednisone 40 mg qd, vioxx 12.5 mg qd, colace, multivitamins, senokot. also of note, he received 300 mg of iv gentamicin and also insulin sliding scale. allergies: no known drug allergies. social history: the patient emigrated from approximately 16 years ago and had previously worked as an accountant. he has no industrial environmental exposures. he had a 60 pack year history of tobacco and quit 20 years ago. he has rare alcohol use. in terms of functional status, he was quite active prior to recent pneumonias but now living in rehab. physical examination: on admission, he is afebrile at 96.9. blood pressure is 101/35. pulse is 85. respiratory rate is 20 and 100 percent on nonrebreather. in general, he is very pleasant and comfortable in no respiratory distress. heent is remarkable for dry mucous membranes. his lungs show diffuse wheezing and decreased air with bilateral rhonchi. his cardiovascular examination shows faint heart sounds and is difficult to appreciate. his abdominal exam is benign. extremities show bilateral ankle edema at 1+. laboratory: labs on admission show a white count of 27.8 which is up from the last time at 18.7. hematocrit is 33, platelet count of 144. his chemistry is sodium 138, potassium 4.7, chloride 103, bicarb 22, bun 43, creatinine 1.6. his baseline is 0.8. his glucose is 146. ast is 16 and alt is 18. alkaline phosphatase is 78. total bilirubin is 0.7. amylase and lipase both are within normal limits. his albumin was 2.7 and lactate was 4.8 subsequently improving to 1.6 after fluid resuscitation. his ua was unremarkable. he had a chest x-ray on admission showing persistent right upper lobe opacity with question of a possible pneumonia when compared to prior chest films. all blood cultures remained negative. urine culture remained negative. he had c. diff sent which was positive. his sputum ultimately grew out stenotrophomonas, pen- resistant with only intermediate sensitivity to levaquin. hospital course by review of systems: cardiovascular: the patient initially came in hypotensive and with increased lactate level was treated empirically for sepsis. the patient was aggressively fluid resuscitated in the emergency room and then started on levophed. by hospital day no. 1, the patient's blood pressures were well over 100 and attempts were made to begin weaning off his levophed. meanwhile, his mixed venous oxygen saturations were well above 70 percent during the majority of his hospital course. although the patient was treated for presumed sepsis, later on it was slightly unclear as to the etiology of the patient's hypotension and whether the patient was truly septic as blood cultures and urine cultures remained negative and sputum grew back bacteria only later on during his hospital course. other sources for hypotension were sought after including cortisol levels which were normal. he ruled out for an mi by cardiac enzymes and then later had an echocardiogram initially to rule out pericardial effusion but which did show a new depressed ejection fraction of 25-30 percent compared with previous values of an ejection fraction of approximately 40 percent. nevertheless, the patient did seem to be fluid responsive initially and met his goal of weaning off of pressors. later during the hospital course, the patient initially came in in sinus rhythm and on ekg developed rapid atrial flutter into the 150's. he was refractory to both diltiazem and beta blockade, but later was started on amiodarone which resulted in conversion back to sinus rhythm with heart rates back into the 60's and 70's. given the fact that his ejection fraction had decreased with signs of cardiomyopathy consistent with rate related tachycardia, one of the concerns was that the patient had become hypotensive in the setting of rapid rates. the timeline for this phenomenon is still, however, unclear. however, as the patient converted back to sinus rhythm, the patient was subsequently easily weaned off of his pressors. furthermore, it was felt that the patient did have a large component of chf as the patient had been aggressively fluid resuscitated. he was later placed on a lasix drip and diuresed nearly 4-6 liters over the span of the later course of his hospitalization with subsequently markedly improved blood pressures. therefore, although the exact etiology of the patient's hypotension is unclear, it is now felt that chf played a large role in this. subsequently, the patient has been optimized in terms of a chf regimen. first, he is being started on an ace inhibitor which is being aggressively titrated up. this can continue to be titrated up as he returns to rehab. as mentioned above, he had been loaded on amiodarone 200 mg . ultimately, it was decided that the patient, given his old age and likely risk of possible bleeding or falls, would not be an ideal candidate for anticoagulation but would optimize the goal for rate control. he is being restarted on a beta blockade and will be placed on an outpatient dose of po lasix. meanwhile, he will be continued on his aspirin and statins for his coronary artery disease. pulmonary: the patient initially was admitted hypotensive and only slightly increased oxygen demands from his new baseline since his multiple hospitalizations this spring. nevertheless, he was somewhat tenuous on 6 liters of nasal cannula and then nonrebreather. again, as mentioned above, it is unclear as to the exact time frame and mechanism of the patient's hypotension and respiratory compromise. initially, it was felt to be septic. however, blood cultures and urine cultures were negative. his sputum ultimately did grow out stenotrophomonas. however, the primary team did not feel that this was clearly an etiology for respiratory failure. it is thought that he may have a possible component of aspiration leading to his respiratory failure. ultimately, the patient was briefly intubated on hospital day no. 3. however, after the patient began to be diuresed and converted to sinus rhythm, the patient was easily extubated on . since that time, the patient's oxygen requirements have now decreased to where he is back on 6 liters nasal cannula with sats into the mid 90's. as mentioned above, his sputum did grow out stenotrophomonas which is pen-resistant. it was felt that this is likely a colonization as evidenced from past evaluations persistently growing out stenotrophomonas. there is the feeling from the team taking care of him that he did not actually have a pneumonia during his hospitalization. however, given his severe structural disease and his cavitary lesion, he would benefit from alternating prophylactic antibiotic regimens with bactrim and amoxicillin to try and decrease his bacterial pathogen load. he will need strict aspiration precautions. he also has been on a slow steroid taper of prednisone for copd which was started on his last hospitalization. please see discharge medications for further instructions on taper. he will continue on his inhalers. he should have strict aspiration precautions. gi: as mentioned above, the patient has a recent history of c. diff. colitis. given his high white count on admission (although his white count is chronically elevated) and still having some loose stools, c. diff. colitis was entertained again. his c. diff. toxins were positive and the patient was empirically started on flagyl. per discussion with infectious disease, the patient should continue on flagyl 10 days following completion of his most recent course of antibiotics, this being the ceftazidime on . as mentioned above, the patient is likely at large risk for aspiration and should take po's with extreme caution. renal failure: the patient came in with acute renal insufficiency. initially, given the patient's hypertension, the patient was felt to be mildly dehydrated and his creatinine did improve with aggressive iv fluid resuscitation. since being placed on iv lasix drip, the patient has had excellent diuresis, although his creatinine has not fallen back completely to baseline. his creatinine should be monitored over the next couple of weeks especially with the addition of an ace inhibitor. however, at this time, the patient's creatinine has remained stable despite aggressively titrating up his medication. heme issues: as mentioned above in the past medical history, the patient has a history of anemia. he will need to be restarted on his iron therapy. also, given his old age and thought to be at risk for subsequent bleeding secondary to falls or possible hemorrhaging, it was decided not to anticoagulate the patient for his atrial fibrillation/flutter but to try to contain him in sinus rhythm. he was also coagulopathic with an inr of 1.6-1.7. this was felt to be possibly secondary to malnutrition and the patient will receive vitamin k for this. it will be useful to follow up his inr to make sure the patient is no longer coagulopathic. finally, the patient has had a slight downward trend of his platelet count during the last several days. his platelet count now is in the 90's. he has been exposed to heparin and a heparin antibody will be sent which will need to be followed up by his primary care physician. endocrinology: the patient was initially maintained on insulin drip while being treated for possible sepsis. he later converted to sliding scale insulin. his thyroid studies suggest possible hypothyroidism with a decreased free t4. however, in the setting of atrial fibrillation, this was decided to be deferred until outpatient for titrating up his medications further. code status: prior to extubating the patient, both the patient and family agreed that he would be willing to be intubated again if necessary. at this point, therefore, the patient should be considered a full code. disposition: the patient will be returning to rehab. discharge diagnoses: atrial fibrillation/flutter with rapid ventricular response, now resolving. chf, exacerbation improving. hypotension, resolved. anemia. acute renal insufficiency. chronic obstructive pulmonary disease on steroid taper. steroid induced hyperglycemia. persistent clostridium difficile colitis. presumed stenotrophomonas colonization of upper airways. condition on discharge: fair. discharge medications: albuterol nebs q4h, aspirin 81 mg qd, lipitor 10 mg qhs, advair 500/50 diskus one puff q12h, folate 1 mg qd, humibid la 1200 mg sr q12h, atrovent nebs q4h, iron sulfate 325 mg , prevacid 30 mg qd, synthroid 75 mcg qd, colace, multivitamins, senokot, captopril 25 mg tid to be continued to be titrated as the patient tolerates, prednisone 30 mg qd and we will have an addendum for taper instructions, toprol 25 mg qd, amiodarone 200 mg , sliding scale insulin. the patient will go home on nasal cannula and bactrim one tablet double strength starting on to . , procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube enteral infusion of concentrated nutritional substances diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified atrial flutter acute respiratory failure intestinal infection due to clostridium difficile pneumococcal pneumonia [streptococcus pneumoniae pneumonia] other and unspecified coagulation defects other specified hypotension 

Answer: The patient is high likely exposed to