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: the patient is an 80 year old male with multiple medical problems including chronic obstructive pulmonary disease with a history of four previous intubations and respiratory distress / respiratory failure, status post recent hospitalization at from until , for respiratory distress and pneumonia, history of left lower extremity cellulitis, history of methicillin resistant staphylococcus aureus in sputum, hypertension, and atrial fibrillation on coumadin. he presented as a transfer from an extended care facility after the onset of increased lethargy, decreased oxygen saturation to 60% on room air. the patient was recently discharged on , after a chronic obstructive pulmonary disease flare with intubation. he was discharged on nebulizer treatments, prednisone, levofloxacin, vancomycin, and metronidazole for empiric clostridium difficile. he finished antibiotic therapy and was doing well at rehabilitation until the day prior to admission. at that time, the staff noticed increased erythema and edema of the left lower extremity, resulting in re-initiation of vancomycin therapy. on the day of admission, the patient was noted to have altered mental status, increased respiratory distress with respiratory rate 28 to 32, and decreased oxygen saturation to 67 to 76%. at that time, blood pressure was 78/50; temperature 97.2; heart rate 110 to 117. on arrival to the emergency department, the patient was moaning, not alert or oriented. respiratory rate was elevated with blood pressure 50s to 60s systolic, heart rate 110 to 120. he was intubated emergently after administration of succinylcholine and atomodate. in the emergency department, he also received solu-medrol 125 mg intravenously; ceftazidine 1 gram; clindamycin 600 mg intravenously. electrolytes were repleted with calcium gluconate 2 grams, magnesium sulfate 4 grams, and he also received intravenous fluid therapy. the patient's blood pressure ranged from 50 to 60 systolic in the emergency department for a good ten to twenty minutes; therefore, a central venous line was placed. the patient was started on dopamine pressor therapy. this resulted in tachycardia to the 150s and therefore dopamine was changed to levophed. blood pressure remained tenuous even after maximum doses of levophed and therefore neo-synephrine was added. past medical history: 1. history of respiratory distress requiring intubation times four in the past, , , , 10/. 2. chronic obstructive pulmonary disease on two to three liters of home o2. 3. history of right lower lobe pneumonia, 10/. 4. left lower extremity cellulitis 09/. 5. epididymitis. 6. history of atrial fibrillation / multifocal atrial tachycardia; ejection fraction of 50% on transthoracic echocardiogram in ; on coumadin for anti-coagulation. 7. hypertension. 8. history of anemia with guaiac positive stools. 9. status post left kidney donation. 10. history of prostate cancer status post radiation approximately seven to eight years ago. 11. history of peptic ulcer disease status post billroth procedure. 12. chronic venous insufficiency. 13. osteopenia, status post multiple compression fractures on chronic opiate therapy. 14. history of vancomycin resistant enterococcus in urine in . 15. hypothyroidism. 16. history of left axillary vein deep vein thrombosis in . 17. history of methicillin resistant staphylococcus aureus positive sputum in 10/. 18. history of burn injuries to thighs bilaterally. allergies: the patient reports no known drug allergies. medications prior to admission: 1. albuterol nebulizer. 2. atrovent nebulizer. 3. diltiazem 120 mg p.o. q. day. 4. multivitamin with minerals. 5. oxazepam 10 mg p.o. q. h.s. p.r.n. 6. synthroid 100 micrograms p.o. q. day. 7. protonix 40 mg p.o. q. day. 8. actigall 35 mg p.o. q. monday. 9. loperamide 2 mg p.o. p.r.n. diarrhea. 10. aspirin 325 mg p.o. q. day. 11. lasix 80 mg p.o. q. day. 12. flovent four puffs inhaled twice a day. 13. oxycodone 5 mg q. four to six hours p.r.n. pain. 14. 20 meq p.o. twice a day. 15. caltrate 600 mg p.o. three times a day. 16. duragesic patch 150 micrograms per hour q. 72 hours. 17. compazine 25 mg p.o. q. day. 18. vancomycin one gram intravenously times two doses for recurrent left lower extremity cellulitis. social history: the patient was discharged after his last hospitalization to facility. he has a significant tobacco history, unknown quantity pack years, having quit tobacco two years ago. he is dependent in all of his activities of daily living. he is incontinent of bowel and bladder at baseline. he is a full code per his daughter. his daughter, , serves as his health care proxy. physical examination: upon admission, temperature 93.7 f.; blood pressure 78/30 up to 127/64 on levophed and neo-synephrine; pulse 102; respiratory rate 25; ventilatory settings at assist control, total volume 600, respiratory rate 14, pressure support zero, peep of 5, fio2 of 100%. general appearance, intubated, sedated, breathing comfortably, in no acute distress; cachectic in appearance. heent: normocephalic, atraumatic. bilateral cataracts. pupils minimally reactive. neck supple with no masses or lymphadenopathy. lungs with bibasilar crackles. scattered rhonchi, anterior laterally with poor air movement. cardiovascular with regular rate and rhythm, s1 and s2 heart sounds auscultated. no murmurs, rubs or gallops. abdomen scaphoid, prominent staples, nodular objects underneath his skin likely from prior billroth procedure. abdomen is nondistended. hypoactive bowel sounds. extremities with left calf with marked erythema, warmth, edema to knee. right leg with chronic venous stasis changes. neurologically: intubated and sedated. moving extremities spontaneously. pupils minimally reactive. not following commands. skin: mottled, cyanotic. laboratory: upon admission, white blood cell count 7.3, hematocrit 31.7, mcv 97, total platelets 393. coagulation profile showed pt 27.5, ptt 49.7, inr of 5.0. serum chemistry showed sodium of 141, potassium 4.3, chloride 110, bicarbonate 21, bun 55, creatinine 4.0. please note patient's baseline is 1.5 to 2.0. cardiac enzymes shows ck 85, mb fraction not performed. troponin t 0.52. the initial chemistry showed calcium 6.0, phosphorus 6.0, magnesium 1.0. urinalysis showed urine to be , cloudy, large blood, 100 protein, moderate leukocyte esterase, nitrites positive. zero to two epithelial cells, greater than 50 white blood cells, moderate bacteria. arterial blood gases right after intubation showed ph 7.09, carbon dioxide 71, oxygen 87, bicarbonate 23, lactate 1.8. chest x-ray showed bilateral diffuse right greater than left parenchymal opacities, not significantly changed from prior study dated . also noted were small bilateral pleural effusions suggestive of aspiration versus pneumonia on top of chronic parenchymal scarring. there was some question of right upper lobe and right lower lobe collapse. ekg was irregularly irregular with no regular p waves; therefore, atrial fibrillation with a ventricular response in the 120s, frequent premature ventricular contractions. there were no acute st-t wave changes. brief summary of hospital course: the patient was admitted to the medical intensive care unit service as a transfer from an extended care facility with increased lethargy, mental status change, respiratory distress, and respiratory failure status post intubation in the emergency department. he required a central venous line placement and multiple intravenous pressors for hypotension, presumed sepsis and severe acidemia. 1. respiratory failure: it was fel that the patient's respiratory failure was most likely secondary to a chronic obstructive pulmonary disease flare due to underlying tracheobronchitis versus pneumonia versus aspiration. he was started on ceftazidine and clindamycin in the emergency department for infectious etiologies as well as coverage for aspiration. vancomycin was added for coverage in light of his history of methicillin resistant staphylococcus aureus positive sputum. the medical intensive care unit staff ended up discontinuing ceftazidime and clindamycin and instead covering the patient with zosyn for additional anti-pseudomonal coverage. he was maintained on an aggressive respiratory regimen with metered dose inhalers, chest physical therapy, aggressive pulmonary toilet and high dose steroids. a ct scan of the chest was performed which showed a large bibasilar pneumonia with a small right pleural effusion. the right pleural effusion was deemed too small for a thoracentesis. the patient was maintained on assist controlled ventilatory setting for several days. he was dramatically over breathing at a rate of high 20s to low 30s, which was his respiratory rate, likely in compensation for his underlying metabolic acidosis. on , the patient became more awake and alert. he was able to undergo a pressure support trial which he tolerated well. he was aggressively diuresed and bicarbonate therapy was added to his medication regimen in order to assist potential extubation. he was extubated on . he tolerated this well and was able to maintain good oxygenation and ventilation on room air. ultimately, the patient's sputum culture grew out methicillin resistant staphylococcus aureus as well as e. coli. in light of the pan sensitivity of the e. coli, the patient's antibiotic regimen was changed to vancomycin and bactrim. he completed a ten day course of antibiotics. steroids continued to be tapered. again, throughout, the patient was maintained on aggressive respiratory therapy regimen with nebulizers and metered dose inhalers, chest physical therapy, aggressive pulmonary toilet. 2. sepsis: the patient had multiple possible sources for sepsis including left lower extremity cellulitis, pneumonia, urinary tract infection. he was originally covered with vancomycin and zosyn. he was pan cultured. a picc line was in place from his last hospital course which was discontinued in light of possible line infection. a catheter tip of culture done was negative. blood cultures had failed to reveal any pathogen. urine culture was positive for yeast. sputum culture was positive for methicillin resistant staphylococcus aureus as well as e. coli. the patient's antibiotic regimen was scaled down in light of sputum culture results and he was maintained on vancomycin and bactrim. he completed a total of a ten day course of both vancomycin and bactrim. vancomycin was dosed by level in light of his chronic renal insufficiency. 3. hypotension: the patient's blood pressure in the emergency department was decreased to 50s to 60s systolic for a prolonged period of time. this required a central venous line placement, intravenous fluids resuscitation and pressor support. he was maintained on levophed, neo-synephrine and vasopressin to keep his mean arterial pressure greater than 65. he was able to have his pressor therapy weaned, and by , was off all pressors. throughout his hospital course, he was aggressively bolused with intravenous fluid to maintain mean arterial pressure greater than 65. at the time of discharge, his hypotension had resolved. 4. acute renal failure: it was felt that the patient's elevated creatinine was likely secondary to atn from sepsis and in light of his prolonged hypotension in the emergency department. renal service was consulted. the patient's urine and sediment was evaluated and was consistent with acute tubular necrosis with muddy brown casts. early on in the hospital course, he had a low urine output, putting out 200 to 300 cc of urine for 24 hours. he was treated supportively with intravenous fluid therapy and eventually his urine output increased. slowly throughout his course, his renal function improved. at the time of discharge, his bun and creatinine were approaching his baseline. 5. acidosis: originally, the patient's acidosis was felt due to respiratory causes, especially in light of his respiratory failure. however, he then demonstrated an anion gap metabolic acidosis. it was felt that this was likely secondary to sepsis as well as acute renal failure. his gap closed with increased peripheral perfusion after a pressor and intravenous fluid therapy. lactate continued to decrease. in order to help correct his underlying acidosis, he was diuresed with lasix; kayciel was repleted and he received supplemental bicarbonate therapy. 6. cellulitis: the patient presented with a left lower extremity cellulitis. he was continued on vancomycin therapy dosed by trough. at the time of discharge, his left lower extremity cellulitis was improving but had not yet completely resolved. he will likely need to continue several doses of vancomycin treatment status post discharge. 7. chronic atrial fibrillation: the patient had a slight troponin leak upon admission. it was felt that this was demand ischemia in the setting of sepsis. there were no ekg changes. creatinine kinase levels remained flat. in light of hemodynamic instability, he was not initially anti-coagulated, however, upon discharge back to rehabilitation facility, he should likely resume coumadin therapy. 8. super-threapeutic inr: the patient had been on coumadin therapy for atrial fibrillation. he also had a history of upper extremity deep vein thrombosis; however, on admission, his inr was markedly elevated greater than 5.0. in light of this, his coumadin therapy was held. the patient should likely restart coumadin upon discharge back to rehabilitation facility in light of his underlying atrial fibrillation. 9. anemia: the patient was anemic on admission. iron, b12, folate, were evaluated. all told, the patient had studies consistent with anemia of chronic disease. he did require several blood transfusions during his hospitalization; however, no frank source of bleeding was defined. on , he had a drop in his hematocrit from 27 to 22. at the time of this dictation, the site of occult bleed was being evaluated. 10. hypothyroidism: the patient had a history of hypothyroidism. he was continued on his outpatient dose of synthroid. 11. fungal urinary tract infection: the patient's urine cultures demonstrated growth of species. he was treated with a five day course of fluconazole. he is likely colonized with the . 12. fluids, electrolytes and nutrition: the patient was originally kept n.p.o. in the setting of sepsis. several days into his hospital course he was begun on tube feeds. he tolerated this well. status post extubation, he was able to tolerate a soft consistency, thickened liquid diet. he should likely undergo a formal speech swallow evaluation and check for aspiration. also on admission it was noted patient's extreme electrolytes abnormalities with hypomagnesemia and hypocalcemia. in light of this, his electrolytes were aggressively repleted. he should likely have his electrolytes followed and repleted as necessary after discharge through the rehabilitation facility. code status: initially, the patient was full code. in light of his underlying severe medical problems as well as this complicated hospital course, discussions were held with his daughter, , discussing his code status. he was made "do not resuscitate" on ; however, the patient's daughter stated that she would like her father re-intubated should he fail extubation. after extubation, the patient's advanced directives were also discussed with the patient himself, and he re-iterated that he would like to be re-intubated should he fail extubation. he also stated that he would not be adverse to tracheostomy placement if he required prolonged ventilatory support. he did, however, state that he would reject percutaneous gastrostomy tube placement as well as hemodialysis if needed to maintain him medically. the remainder of the hospital course, including condition on discharge, discharge status, discharge diagnoses and discharge medications with follow-up plans will be dictated as a separate addendum to this report. , m.d. dictated by: medquist36 d: 17:11 t: 17:53 job#: 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 transfusion of packed cells diagnoses: acidosis acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified septicemia atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure cellulitis and abscess of leg, except foot methicillin susceptible pneumonia due to staphylococcus aureus 

Answer: The patient is high likely exposed to