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: sulfonamides / iodine; iodine containing / phenytoin / levaquin / neurontin / ace inhibitors attending: chief complaint: fever, tachypnea major surgical or invasive procedure: placement of plate and flap for sternal wound closure a line central line history of present illness: 66m w/cad s/p cabg x2 (most recently c/b multiple admissions with wound dehiscence, wound infection), pna (mrsa, acinetobacter), chf, copd, htn who was discharged from ~10 days ago to vent rehab (ne ) for continued weaning. pt was noted to have fever to 102 and tachypnea (vent was on ps) beginning ~1 day pta so was sent to ed (initially hospital then @ family request) where cxr revealed pna. at osh , pt rec'd ceftriaxone x1. <br> in ed here, wbc 26 with 10 bands, lactate 1.6. in addition, abg 7.17 / 79 / 179 on ps 10, peep 5 so changed pt to ac. sbp was initially stable in 100s but decreased to 70-80s despite 2l ns so started on neosynephrine. <br> on admission, pt was somnolent but arousable and shakes his head when asked if he is in any pain. per pt's wife & daughter, m.s. had been at his recent baseline (a&ox2-3) earlier today but has been more somnolent x few hours. past medical history: -cad: s/p cabg x2, most recently in c/b wound dehiscence s/p pectoralis flap procedure w/ recurrent wound dehiscence and requiring exploration (by plastic surgery). -h/o pseudomonas pna -rib osteomyelitis -tracheal bronchitis (cipro, vanco, tobramycin to cover bronchitis and wound infection) -chf: last ef was 44% at cath () -htn -hypercholesterolemia -severe copd on home o2 & ?chronic steroids -lung cancer: s/p rll lobectomy no chemo/radiation currently no evidence of recurrent disease -gerd and pud -bph -anemia -h/o shingles -depression social history: 160 pack year history of tobacco - quit 3 years ago. no recent etoh. usually lives with wife but has been at ne vent rehab since d/c on . former globe worker. family history: significant for premature coronary artery disease. father and brothers were diagnosed in their 30's. physical exam: -vs: 100.4->98.8, hr 90-100, bp 111/61 -> 70-80s/40s, 99-100% on vent -gen: middle-aged m intubated -skin: sternotomy site w/vac dressing, trach site c/d/i, g-tube site c/d/i -heent: ett in place, perrla (2mm->1mm) bilaterally -heart: s1s2 rrr, distant heart sounds -lungs: coarse upper airway sounds throughout; trace sacral edema -abdom: soft, obese, nt, nd nabs -extrem: 1+ dp pulses, trace le edema -neuro/psych: alert, follows simple commands, moving all extremities equally pertinent results: -ecg: sinus tach, l-axis, flat tw diffusely but no acute st/tw changes. unchanged from old. -cxr: bilat pna, l-sided pleural effusion chest ct without contrast: 1. progressive enlargement of a spiculated nodule in the left upper lobe, concerning for recurrent lung cancer. 2. unchanged segmental atelectasis/consolidation in the left lower lobe. 3. unchanged centrilobular nodules in the dependent portions of the lower lobes, consistent with an infectious or inflammatory process. 4. no evidence of an acute pathologic process in the abdomen on limited non-contrast evaluation. 5. sigmoid diverticulosis, without evidence of acute diverticulitis. 6. gas in the bladder in the absence of a foley catheter. please correlate with any recent history of instrumentation. renal ultrasound: the right kidney measures 13.2 cm and appears normal without evidence of stones, mass or hydronephrosis. the left kidney measures approximately 13 cm and demonstrates a massively dilated collecting system and a thin rim of remaining cortex measuring approximately 5 mm. the left kidney demonstrates no evidence of stones or mass. impression: normal-appearing right kidney. end-stage hydronephrotic left kidney consistent with chronic obstruction. echo: the left atrium is dilated. the right atrium is dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. overall left ventricular function appears preserved. right ventricular chamber size and free wall motion are probably normal. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: no vegetation or abscess seen. aerobic bottle (final ): reported by phone to pat, -cc6d- @ 13:40 . albicans. albicans. 2nd morphology. anaerobic bottle (final ): no growth. 6:57 pm bronchial washings **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): squamous epithelial cells. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): rare growth oropharyngeal flora. pseudomonas aeruginosa. sparse growth. staph aureus coag +. sparse growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | cefepime-------------- =>64 r ceftazidime----------- =>64 r ciprofloxacin--------- 1 s clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ =>16 r <=0.5 s imipenem-------------- =>16 r levofloxacin---------- =>8 r meropenem------------- =>16 r oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- =>128 r piperacillin/tazo----- =>128 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ =>16 r vancomycin------------ <=1 s 12:57 pm urine **final report ** urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivity testing confirmed by sensititre. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s chloramphenicol------- <=4 s levofloxacin---------- =>8 r linezolid------------- 2 s nitrofurantoin-------- <=16 s vancomycin------------ =>32 r 10:50 pm swab site: sternum source: sternal wound. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): acinetobacter baumannii. sparse growth. tigecycline mic= 12ug/ml. unasyn (ampicillin/sulbactam) and tigecycline per dr (). sensitive to colistin <=2 mcg/ml (performed at laboratories). meropenem and piperacillin/tazobactam sensitivity testing performed by . staph aureus coag +. rare growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. sensitivities: mic expressed in mcg/ml _________________________________________________________ acinetobacter baumannii | staph aureus coag + | | ampicillin/sulbactam-- =>32 r cefepime-------------- =>64 r ceftazidime----------- =>64 r ciprofloxacin--------- =>4 r erythromycin---------- =>8 r gentamicin------------ =>16 r <=0.5 s imipenem-------------- 8 i levofloxacin---------- =>8 r =>8 r meropenem------------- r oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin/tazo----- i rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ 8 i trimethoprim/sulfa---- <=1 s vancomycin------------ <=1 s brief hospital course: 66m w/cad s/p cabg x2 (most recently c/b multiple admissions with wound dehiscence, wound infection), pna, chf, copd, htn who was recently discharged to vent weaning rehab now a/w pna and hypotn, s/p abx course. . sternal surgical wound (s/p 2 failed flap procedures in past): vac dressing was in place at rehab but pt's wound had pus upon admission. plastics consulted & followed while in house. most recent wound cultures from early grew acinetobacter, mrsa and enterobacter. plastics sent pt for a sternal flap procedure friday , where a plate and sternal flap were placed. in general, these have been resistant organisms. he was desensitized to bactrim and has been continued on iv bactrim, vanc, and meropenem for therapy of organisms within his wound. he is felt to be at high likelihood for recurrence of resistant infections and at this point, will likely require life-long abx therapy. his wound has improved in appearance since his most recent i/d from . his jp drains were d/c'd. vanco should be dosed by level, give if level<20 . bacteremia: early blood cx () during this hospital course grew out albicans so he was started on caspofungin & switched to fluconazole for 2 week course. tte & tee without evidence of vegetations, and optho exam without lesions. most recently, developed enterobacter bactermia with last positive cultures on . as mentioned above, he remains on life long broad spectrum abx at this point. . respiratory failure: pt has severe copd at baseline with most recent fev1 of 40% and is also s/p lung resection. he was trach'ed following cabg and his hospital course has been plagued by difficult wean off vent support. etiology of respiratory failure thought to be mutlifactorial, including copd, volume overload, ventilator associated pna, severe anxiety/agaitation, and abnormal chest wall abnormality. he often complained of dyspnea without objective evidence of impaired oxygenation/ventilation. it is felt that he does have real dyspnea that unfortunately may never be resolved. traditionally thought to have steroid depedent copd although steroids were progressively weaned during course and at times were completely off (see below). he has been diuresed with iv lasix for volume overload. meanwhile, he has continued on broad spectrum abx including vanc, meropenem, and iv bactrim. he has had prior mrsa pna's. of note, he does have evidence of pseudomonas in sputum which is sensitive only to amikacin. it has been the strategy of id and primary team, not to initiate amikacin unless there is evidence of fevers, increased sputum production. he was started on colistin ih . low threshold should exist for starting amikacin with 1200 mg 1st dose followed by 600 mg following. finally, pt thought to have severe anxiety and agitation inhibiting progress on vent. difficult to find balance between comfort and oversedation. pt has had gentle increase in clonopin. psych was consulted and recommeded using zyprexa . as mentioned above, pt has become increasingly trach depednent and there is some doubt as to whether patient will ever become independent despite lacking objective evidence of dyspnea. over the past several days, he has again been able to wean off pressure support with intermittent trach collar trials. he does have meur valve and the motivation to speak. upon d/c patient was on ps 10/5 with fio2 of 40%. . cad: s/p cabg ( was surgeon). ecg unremarkable. echocardiogram revealed ef 65%. pt was continued on asa, plavix. his ef was 44% pre-cabg, but most recent echo demonstarted preserved systolic function with evidence of impaired relaxation. started on low dose bb for hypertension. chf: most recent echo thought c/w impaired relaxation. fluid overload thought to play component in pt's resp failure. accordingy, he had been diuresed with iv lasix. rate control has been with bb. . hypotension: he had intermittent episodes of hypotension, as well as a known history of adrenal insufficiency. these episodes were usually in the setting of infection and underlying adrenal insufficuency. he was intermittently tapered down on steroids as tolerated, but then re-started on stress dose steroids in the setting of infection or surgery. he was also started on fludricortisone for hyponatremia and hyperkalemia, which resolved with treatment. however, by mid , pt's hyponatremia had resolved and pt was notably hypertensive. florinef was d/c'd and pt underwent a slow taper off prednisone. despite his family's argument's, pt showed no signs of bronchospasm off steroids and remained hemodymically stable. given his complex id issues and less than ideal wound healing, the primary team felt that minimizing steroids would help to improve wound healing. he was off steroids for a large majority of week of but when developed new fevers, and hypotension on , was restarted on hydrocortisone. his blood pressures improved and he has been tolerating a steroid wean well. . lul lung nodule: this was first noted in ct chest (had increased from 6 mm ? -> 11 mm). it was later noted to have increased to 13 mm by ct & mri and . repeat chest imaging on demonstrated further increase in nodule size from previous examinations. findings are concernng for maligancy although family has requested that pt not be notified of recurrent nodule. thoracics surgery was consulted for consideration of biopsy but given location and pt's complex chest anatomy advised against further evaluation via biopsy. family had requested head ct which was unrevealing for evidence of mets. not unreasonable to repeat chest ct in near future although at this point, pt is unfortunately a poor candidate for either surgical or chemotherapy. it was relayed to family that this evaluation should be placed on the side while patient tries to overcome his other serious illnesses. should patient recover post discharge, a pet could be considered. family does not want to tell patient about lung nodule as he is too sick with other things. an ethics consult was called and the decision was made to not tell patient about nodule as he told the team that he likes that his daughter filters information for him and that he didn't need to know everything. anemia: has intermittently required transfusions during hospital stay with baseline crits in high 20's. he is currently receiving epogen and iron although iron studies c/w anemia of chronic dz. b12/folate have been unrevealing. in general, despite daughter's argument, he should not be transfused unless crits less than 21 or active evidence of bleeding. . fen: he has peg in place and has tolerated tube feeds. he has passed swallow evaluation with fees and may eat when on vent settings (ps 10/5). . contact: wife and daughter () are extremley involved in care. is hcp and is to be notified of any changes in status. at this point, pt remains full code. medications on admission: -rec'd ceftriaxone at osh ed am of admission -metoprolol 50 tid -asa 81 daily -plavix 75 daily -lipitor 20 daily -flagyl 500 tid (unclear indication) -clonazepam 0.5-1 -ativan prn anxiety -lovenox 30 mg daily -nexium 20 mg daily -iss starting at fs glc 200 -mssr 45 -msir 5 mg prn -morphine 4 mg iv prn -prednisone 20 daily -ipratropium q4h -singulair 10 daily -albuterol q4h & prn -tamsulosin 0.4 daily -tylenol prn -vitamin c -ca++ acetate 667 tid -colace, senna, lactulose <br> <h3>allergies: neurontin dilaudid levoflox lisinopril hydantoin derivatives phenytoin discharge disposition: extended care facility: discharge diagnosis: primary: vent associated pna with pseudomonas and mrsa acinetobacter wound infection sepsis respiratory failure fungemia renal failure, hyperkalemia lung ca recurrence secondary: -cad: s/p cabg x2, most recently in c/b wound dehiscence s/p pectoralis flap procedure w/ recurrent wound dehiscence and requiring exploration (by plastic surgery). -h/o pseudomonas pna -rib osteomyelitis -tracheal bronchitis (cipro, vanco, tobramycin to cover bronchitis and wound infection) -chf: last ef was 44% at cath () -htn -hypercholesterolemia -severe copd on home o2 & ?chronic steroids -lung cancer: s/p rll lobectomy no chemo/radiation currently -gerd and pud -bph -anemia -h/o shingles -depression -s/p appy, s/p chole, s/p cataract surgery, s/p nissen, s/p wound dehiscence and infection, s/p cabg x2. discharge condition: fair discharge instructions: -continue vent weaning as tolerated. please change dressings on blanching. -continue vancomycin/bactrim/meropenem indefinitely followup instructions: please arrange for follow up with pcp: , . within 2 weeks. his recurrent lung cancer needs to be further evaluated once he is stable. 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 enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] attachment of pedicle or flap graft to other sites bronchoscopy through artificial stoma transfusion of packed cells injection or infusion of oxazolidinone class of antibiotics revision of pedicle or flap graft internal fixation of bone without fracture reduction, scapula, clavicle, and thorax [ribs and sternum] diagnoses: hyperpotassemia other postoperative infection urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) severe sepsis chronic airway obstruction, not elsewhere classified pneumonia due to pseudomonas malignant neoplasm of bronchus and lung, unspecified septic shock methicillin susceptible pneumonia due to staphylococcus aureus other septicemia due to gram-negative organisms acute osteomyelitis, other specified sites chronic respiratory failure other and unspecified mycoses disruption of external operation (surgical) wound attention to tracheostomy mechanical complication due to graft of other tissue, not elsewhere classified 

Answer: The patient is high likely exposed to