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: penicillins attending: chief complaint: lethargy major surgical or invasive procedure: 1. intubated 2. central line placement history of present illness: 082 y/o f w/sjogren's syndrome s/p numerous prolonged hospitalizations at earlier this year for gi bleed, pelvic abscess, complicated by hemoptysis, resp failure req trach, cdiff, adrenal insufficiency, anemia, arf requiring hd, dvt, acute proliferative glomerulonephritis, transferred to for further management. had a very long vent wean at but was doing well until 2 days ago, developed resp distress requiring increased ventilatory support, increasing secretions from trach, weight increased approx 10 pounds over 2 weeks and increased fio2 requirement overnight. blood cx from grew gram negative rods 2/4 bottles, sputum cx grew 2 different species of pseudomonas. cxr at showed rll infiltrate vs atelectasis. her wbc increased from 12 to 29, her creatinine increased to 2.2 from 1.8. her fio2 requirement increased from 40% to 100%, and her abg on the fio2 of 100 was 7.34/45/102. she received vanc for increasing secretions and resp distress, aztreonam 500 mg x1, gent 5 mg/kg x1 for gnr bacteremia. in the ed, she was afebrile (98.8) and hemodynamically stable (bp 140s, tachy in 100s). her fio2 was at 70%. she was noted to have acute renal failure at 1.8 (but 2.0 at ), and was hyperkalemic at 6.3. she was given insulin/glucose, bicarb, and kayexalate and transferred to the micu. past medical history: 1. respiratory failure: had large pleural effusions and bilateral pneumothoraces, s/p chest tube placement, s/p talc pleurodesis. s/p trach, has been off vent x3 weeks, placed back on it 2 days ago 2. sjogren's 3. glomerulonephritis, proliferative. rx with prednisone and cytoxan, required hd . 4. r popliteal dvt , rx with heparin gtt and coumadin for approx one month (stopped when admitted with gi bleed) 5. chf, ef 55% 6. thrombocytopenia felt cytoxan (nadir at 40, had been in 200s prior to d/c in ) 7. gi bleed adm early : gastritis, esophagitis on egd, proctitis with erythema and small ulcers, diverticulosis on colonoscopy. readmitted with gi bleed later that month, underwent left colectomy, appy, colorectal anastomosis, and gastrostomy. 8. pelvic abscess, adm , s/p drainage by surgery. 9. elevated lfts during hospitalization, unclr etiology s/p extensive w/u 10. hx cdiff colitis, treated with flagyl, oral vanc, linezolid 11. serratia uti (esbl), rx with cefepime 12. adrenal insufficiency 13. raynaud's 14. cryoglobulinemia 15. peripheral neuropathy 16. paget's disease, found incidentally on ct scan 17. secondary hyperparathyroidism social history: lived at home with her 83 y/o sister prior to hospitalization in , has been at since. worked as an administrative assistant, retired . never married, has no children. no hx tobacco. used to drink alcoholic drinks/week. family history: positive for gastric cancer in father, otherwise negative. no autoimmune disease. physical : t: 98.8 bp: 148/102 p: 105 vent settings: ac 400 x 15 (breathing 25) fio2 70% peep 5, ps 17, o2 sat 100% gen: ill-appearing female, with tremor in upper ext and tongue, opens eyes to voice, responds to questions appropriately heent: normocephalic, atraumatic, anicteric, perrl, mouth open with dry mucous membranes neck: trach collar in place, difficult to assess jvd, no cervical lad lungs: coarse rhonchi throughout, worst at left base, decreased breath sounds at right base cv: regular rhythm, tachycardic, no murmurs, rubs, or gallops abd: mildly distended, tenderness to deep palpation in bilateral lower quadrants without rebound or guarding, +bs. ext: dressings in place over bilateral lower extremities, 2+ pitting le edema skin: innumerable areas of skin breakdown throughout, per nsg notes has stage ii sacral decub. no erythema or purulent drainage at catheter site. neuro: follows commands in upper extremities, unable to do so in lower extremities pertinent results: 04:32pm blood wbc-26.6* rbc-3.46* hgb-10.3* hct-31.4* mcv-91 mch-29.9 mchc-32.9 rdw-17.7* plt ct-125*# 04:32pm blood neuts-78* bands-12* lymphs-3* monos-3 eos-0 baso-0 atyps-0 metas-3* myelos-1* 04:32pm blood pt-12.8 ptt-24.0 inr(pt)-1.1 04:32pm blood glucose-116* urean-128* creat-1.8* na-134 k-6.3* cl-99 hco3-24 angap-17 04:32pm blood alt-25 ast-29 alkphos-148* amylase-57 totbili-0.3 04:32pm blood lipase-34 04:32pm blood calcium-8.3* phos-3.2 mg-1.9 06:29pm blood k-5.8* 04:42pm blood lactate-2.7* k-6.4* 05:10pm urine color-straw appear-clear sp -1.008 05:10pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-mod 05:10pm urine rbc-0-2 wbc-* bacteri-mod yeast-few epi-0-2 cxr: rul and lll opacities, mod r effusion ecg: rate 100, sinus, normal axis, normal intervals, twi in i and avl (old), v5-6 (new), st elevation 0.5 mm v2-3 (new), isolated peaked t in v3 sputum culture: klebsiella pneumoniae, pseudomonas aeruginosa sputum culture: stenotrophomonas (xanthomonas) maltophilia, pseudomonas, yeast labs on d/c: urine culture: yeast >100,000 organisms 03:45am blood wbc-13.0* rbc-3.68* hgb-10.7* hct-32.0* mcv-87 mch-29.1 mchc-33.4 rdw-17.1* plt ct-258 03:45am blood plt ct-258 03:45am blood glucose-102 urean-108* creat-1.1 na-138 k-5.0 cl-100 hco3-27 angap-16 03:45am blood calcium-7.9* phos-7.1* mg-2.0 03:45am blood vanco-11.6* 02:43pm blood type-art temp-36.7 rates-/24 fio2-40 po2-60* pco2-45 ph-7.40 calhco3-29 base xs-1 intubat-not intuba brief hospital course: 1. resp failure: the etiology of this was felt to be a combination of pseudomonal pneumonia plus pulmonary edema. id was consulted who recommended treating the pseudmonas with meropenem since it was sensitive, and because it was sensitive she did not need to be double dovered. she was also diuresed with lasix as tolerated. she also had a pleural effusion that was very small (history of talc pleurodesis due to pleural effusion). an ultrasound was done to evaluate the effusion but it appeared to be too small to tap. she was also given a dose of vancomycin in the ed because of the degree of her illness. she was on ac ventilator setting for most of her hospital stay, but over the past 2-3 days she has tolerated cpap+ps (ps 10, peep 5) and short sprints (2-3 hours) on trach collar. 2. bacteremia: she grew pseudomonas from her blood at , and the most likely source was felt to be her quinton catheter given that it had been in for over 6 months. this was removed by surgery on , although the tip culture was negative. she was covered with meropenem 500 iv q12h, and was started on gentamicin before the sensitivities from were received which revealed 2 strains of pseudomonas, one of which was resistant to gentamicin. gentamicin was then stopped and she was continued on meropenem. she remained afebrile and her leukocytosis improved. her blood pressure remained elevated throughout her hospital course. 3. renal failure: had extensive w/u in the past, biopsy consistent with glomerulonephritis, treated with prednisone and cytoxan. her creatinine was elevated on admission but trended down to 1.1 by discharge. this was felt to be due to intravascular volume depletion. her acei was held given her elevated creatinine. 4. anemia/thrombocytopenia: she has a history of chronic anemia and required numerous transfusions as well as epo during her prior hospitalizations. she also has a hx of gi bleed but was guaiac negative while here. she was transfused here twice, (one unit prbcs each time) for hct 25 and 26 respectively. she had appropriate responses to the transfusions. her thrombocytopenia has been worked up extensively in the past and was felt to be due to cytoxan (numerous negative hit antibodies). her platelets normalized while she was here. 5. hyperkalemia: likely due to renal failure plus acei. came down with insulin/glucose/bicarb/kayexalate. no ecg changes. 6. ecg changes: most likely demand ischemia in setting of tachycardia and sepsis, with new lateral twi's. also have some beta-blocker withdrawal as it has been held at given her sepsis. cardiac enzymes were negative. beta-blocker was restarted with no adverse effects. 7. history of adrenal insufficiency: prednisone continued at current dose. 8. afib/hypertension: near the end of her hospital course, pt's bp started to run high. her outpt regimen of labetalol and amlodipine were reinstated, but she remained hypertensive. her original regimen was doubled, and hydralazine 20 q6h was added to keep her bp under control. 9. fen: tube feeds continued throughout hospitalization. surgery was consulted for excessive leakage around the g-tube site. only recommendations were to try inflating the balloon another 5cc to create a tighter seal. in terms of her elevated phosphate on d/c, the etiology of this was unclear but she has a history of secondary hyperparathyroidism. she may need to be on nepro tube feeds to lessen her phosphate intake. this should be followed up by her pcp. was also hypernatremic during this admission (peaking at 150) which was treated with free water boluses per g tube (200 q 4 hours). this should be monitored closely and adjusted as needed. medications on admission: lasix 40 iv q12h labetalol 200 mg tid captopril 6.25 mg qid albuterol nebs ativan 0.25 mg q2h prn anxiety artificial tears tylenol 650 mg q4h prn zofran 4 mg q4h prn prevacid 60 mg po bid vitamin c 500 mg daily prednisone 20 mg daily ursodiol 300 mg q12h oxycodone 5 mg q4h prn kcl 40 meq daily given : gent 270 mg iv x1 (5 mg/kg) vanc 1 g x1 aztreonam 500 mg x1 tube feeds discharge medications: 1. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 2. lansoprazole 30 mg susp,delayed release for recon sig: two (2) po bid (2 times a day). 3. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ascorbic acid 90 mg/ml drops sig: five (5) po daily (daily). 5. lorazepam 0.5 mg tablet sig: 0.5 tablet po q4-6h (every 4 to 6 hours) as needed. 6. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 7. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 9. acetaminophen 160 mg/5 ml solution sig: two (2) po q4-6h (every 4 to 6 hours) as needed. 10. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 11. labetalol 200 mg tablet sig: two (2) tablet po tid (3 times a day). 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 13. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours) for 7 days. 14. morphine 2 mg/ml syringe sig: one (1) injection q4h (every 4 hours) as needed for dressing change. 15. hydralazine 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: - pseudomonas pneumonia - pleural effusion - line infection secondary: - bacteremia - hypertension - anemia - peg leakage - renal failure - sjogren's syndrome - chf - thrombocytopenia - adrenal insufficiency discharge condition: stable, on ventilator, to complete outpt course of antibioitcs, discharged to rehab for further vent weaning and management discharge instructions: 1. take medications as directed. you have been started on merepenem - you will need to complete 2 week course of antibiotics, which you will finish on . 2. follow up as scheduled. 3. seek immediate medical attention for fevers, chills, respiratory distress or worsening hypoxia, mental status changes or other concerning changes. followup instructions: please follow up with your pcp weeks, dr. . please call to schedule. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization diagnoses: hyperpotassemia anemia, unspecified congestive heart failure, unspecified acute kidney failure, unspecified severe sepsis atrial fibrillation acute respiratory failure pneumonia due to pseudomonas pressure ulcer, lower back infection and inflammatory reaction due to other vascular device, implant, and graft hyperosmolality and/or hypernatremia gastrostomy status tracheostomy status septicemia due to pseudomonas sicca syndrome secondary hyperparathyroidism, non-renal 

Answer: The patient is high likely exposed to