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: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain/vomiting major surgical or invasive procedure: ex lap enterotomy repair bedside washout, enterotomy repair bedside washout, ileal drain, vac placement bedside washout, repair of enterotomy bedside washout, luq drain placement trache and vac change stsg to abdomen from left thigh ftsg to left face from left chest picc sternal pustule i&d history of present illness: vs: t 98.6 hr 130 bp 119/67 rr 20 98% gen: nad, appears uncomfortable, aaox3, answers questions heent: dry mucous membranes, no scleral icterus chest: cta b/l, no wheezes, rales, rhonchi heart: s1/s2, sinus tachy abd: soft, well-healed midline scar, g-tube to gravity draining greenish fluid, mildly distended, slightly tender periumbilical (was given morphine, unable to assess for peritoneal signs), bs normoactive ext: warm, 2+ edema labs: 142 113 16 agap=12 -------------< 110 3.8 21 0.9 ca: 7.9 mg: 2.3 p: 2.5 alt: 10 ap: 186 tbili: 0.5 alb: 2.2 ast: 11 lip: 72 11.6 8.4 >< 374 36.9 n:73.2 l:24.0 m:2.1 e:0.1 bas:0.6 pt: 16.3 ptt: 30.0 inr: 1.4 ct abd (wet read from osh): dilated loops of small bowel, measuring up to 5 cm, with transition in distal ileum. distal and terminal ileum are collapsed, compatible with sbo. no free air or pneumatosis. moderate sized pleural effusions bilaterally. small free fluid throughout abdomen. past medical history: dyslipidemia hypertension migraines s/p hysterectomy h/o amaurosis fugax s/p cervical disc surgery yrs ago osteoarthritis social history: -married with several children. family supportive - 3 children-tobacco history: 45 pack year history (current) -etoh: occ -illicit drugs: denies family history: sister died of pancreatic cancer a few months ago. no stroke , cad physical exam: vs: t 98.6 hr 130 bp 119/67 rr 20 98% gen: nad, appears uncomfortable, aaox3, answers questions heent: dry mucous membranes, no scleral icterus chest: cta b/l, no wheezes, rales, rhonchi heart: s1/s2, sinus tachy abd: soft, well-healed midline scar, g-tube to gravity draining greenish fluid, mildly distended, slightly tender periumbilical (was given morphine, unable to assess for peritoneal signs), bs normoactive ext: warm, 2+ edema labs: 142 113 16 agap=12 -------------< 110 3.8 21 0.9 ca: 7.9 mg: 2.3 p: 2.5 alt: 10 ap: 186 tbili: 0.5 alb: 2.2 ast: 11 lip: 72 11.6 8.4 >< 374 36.9 n:73.2 l:24.0 m:2.1 e:0.1 bas:0.6 pt: 16.3 ptt: 30.0 inr: 1.4 ct abd (wet read from osh): dilated loops of small bowel, measuring up to 5 cm, with transition in distal ileum. distal and terminal ileum are collapsed, compatible with sbo. no free air or pneumatosis. moderate sized pleural effusions bilaterally. small free fluid throughout abdomen. pertinent results: ct abd/pelvis: dilated loops of small bowel, measuring up to 5 cm, with transition in distal ileum. distal and terminal ileum are collapsed, compatible with sbo. no free air or pneumatosis. moderate sized pleural effusions bilaterally. small free fluid throughout abdomen. echo - small lv with ef 40%. 4+ tricuspid regurgitation. no effusion. cxr - moderate b/l pleural effusions with adjacent bibasilar atelectases have increased on the left. there is new mild vascular congestion. cxr - interval increase in mediastinal vascular caliber - probably pulmonary edema. progressive rml consolidation. cxr - bibasilar effusions and consolidation, unchanged pulmonary edema. cxr - the endotracheal tube, swan-ganz catheter, left-sided central venous catheter, and feeding tube are all unchanged in position. there is increase in the bronchovascular markings compatible with some fluid overload. there are more confluent areas of consolidation within the bases, which may represent fluid overload versus aspiration. left retrocardiac opacity is seen. there is increase in the left-sided pleural effusion since the previous study. echo - left ventricular cavity is unusually small, lvef 50-55%. right ventricular cavity is dilated with moderate global free wall hypokinesis. severe tricuspid regurgitation is seen. cxr - multifocal pneumonia most notable in left upper and right lower lung. decreased pulmonary edema. cxr - bibasilar opacifications are again consistent with atelectasis and effusion. there is increasing indistinctness of pulmonary vessels, consistent with pulmonary edema. cxr - no evidence of pneumothorax. resolving left upper and right lower lobe consolidation. unchanged left lower lobe atelectasis and subsegmental right lower lobe atelectasis. echo - improving lv/rv function, ef 50% 9/15 cxr - ogt advanced cxr - slight increase in pre-existing opacities at the right lung base, including a basolateral rounded area of consolidation. no new opacities. cxr - essentially stable, continued fluid overload cxr - there is mild cardiomegaly. bibasilar opacities left greater than right are unchanged, could be atelectasis but superimposed infection cannot be totally excluded. small bilateral pleural effusions are stable. pulmonary edema has markedly improved, now mild. cxr - unchanged ruq u/s - no definite fluid collection. trace ascites, small right pleural effusion. cxr - atelectasis vs. pneumonia radiographically indeterminate cxr - increased opacity in the left perihilar and lower lung that might be consistent with unilateral pulmonary edema versus aspiration cxr - stable lll collapse, increased r effusion cxr - decreased r effusion cxr - this could reflect increasing aspiration or worsening diffuse pulmonary edema. cxr - interval improvement in pulm edema, but still present bibasilar consolidations and bilateral eff substantial. cxr - mild improvement in pulmonary edema, stable b/l effusions echo: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. there is mild to moderate regional left ventricular systolic dysfunction with akinesis/aneurysm of the basal half of the inferior wall. the remaining segments contract normally (lvef = 45 %). no intraventricular thrombus is seen. the right ventricular cavity is moderately dilated with focal basal free wall hypokinesis. there is abnormal septal motion/position. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is a trivial/physiologic pericardial effusion. compared with the findings of the prior study (images reviewed) of , the right ventricular cavity is smaller with slightly improved systolic function. the severity of mitral regurgitation is increased. cxr: minimal increase in r pleural effusion, l pleural effusion unchanged. ct face: subcutaneous edema, fat stranding, and fascial thickening extending from the left lateral orbit to the left mandible without evidence of drainable fluid collection. soft tissue opacification of the sphenoid sinus, mastoid air cells and the external auditory canal bilaterally. : echo indicates slight improvement in rv function (with slight worsening of mr). cxr: continued bilateral pleural effusions with bibasilar atelectatic change. cxr: little overall change in the appearance of the heart and lungs except for some increase in the retrocardiac opacification cxr: persistent bilateral pleural effusions and retrocardiac opacity. : lle u/s - limited exam as patient unable to tolerate. no dvt seen in left common femoral vein. cxr: stable appearance of bilateral pleural effusions and large retrocardiac opacity. cxr: persistent mod pl effusions with apparent loculation on the right : b/l le us - no dvt; psych states pt is delirious, recommend replace benzo when given for anxiety w/ haldol (or zyprexa), & check qtc. cxr: moderate-to-severe cardiomegaly unchange since . edema improved since . right pleural effusion unchanged or slightly smaller. chronic lll collapse. cxr: no short interval change in r pleural effusion, lll atelectasis and mild edema. unilat up ext veins us left:no evidence of deep vein thrombosis in the left arm. fistulogram: loop of bowel in direct communication with the anterior abdominal wall. no distal obstruction of contrast material beyond the fistulous tract is identified. axr:no contrast w/in abdomen after fistulogram. ct head: no acute intracranial process. blood cx: coag neg staph in bottles (from picc). urine cx: citrobacter, klebsiella, enteroccocus (vre) urine cx: enterococcus (vre) and pseudomonas brief hospital course: this is a 68 y/o female s/p cardiac surgery service of after a rv mi requiring a rvad,who returned with sbo.she was admitted to the icu and underwent ex lap,lysis of adhesions, small bowel resection x3, small bowel entero-enterostomy with terminal ileum/colon discontinuation and temporary abdominal closure. intra-op she received 3l crystalloid, 500 cc albumen, 4 u ffp, 5 u prbc, and ebl was 2l. uop in case was only 100 cc. the patient required pressor support intra-op. post-op labs stable, hct 35.7. patient was tachycardic to 120-140s,with hypotension, and was started on neo gtt for pressure support. on hd 3,the patient received 9l lr boluses and 500ml albumin for low pressures. cefazolin was re dosed to 2g q8hr. foley was changed for yeast in urine. hands/ feet noted to be mottled (neo at low doses).on hd 4,: pt was transfused 2u prbc and 4u ffp. on hd5, the pt was taken to the or for washout and repair of leak. : sputum grew yeast and fluconazole started. a bedside ex lap was performed - leak at staple line was over sewed, small bowel decompressed. tpn was started. washout was performed, enterotomy was found and closed. : started on milrinone, changed to vasopressin; repeat echo w/ improved lv/rv function, : ex lap in am with washout, replacement terminal ileostomy tube and repair enterotomy. stim test without adequate response hydrocortisone started. yeast in urine - changed foley and culture urine; cipro discontinued and replaced with cefepime for pseudomonas coverage given sensitivities from picc. : started 1/2ns @ 75cc/hr, epi weaned : bile drained from wound sump, ex-lap'd and washout at bedside, ileostomy tube re-sewn, bile appeared to be coming from ruq, dc'd hydrocortisone : ruq u/s ordered to eval biliary leak and elevated alk phos and bili, pan cx, fluconazole changed to micafungin, heparin started, trending q6h lactate. : patient opened at bedside for bile leak in am and at noon, bile leak noted at ileostomy tube site, enterotomy at staple line repaired; 250cc albumin x3 for sbp in 80s, neo up to 1 : ivf increased to 150ml/hr, tpn continued. repeat bcx sent. the patient was bronched with removal of thick sputum. a bal was sent and cxr showed improved aeration. the ij was rewired concern for infection. : ivf decreased and tpn continued. : off sedation, on neo 0.5, prn albumin boluses for hypotension, +2.5l , tpn continued, washout of abdomen was uneventful : off pressors, fluids even for . wound vac changed. re-bronched, bal sent. : tachypneic with rising pco2, required cmv overnight. : lue duplex to eval swelling negative for dvt. ivf to kvo, 20mg lasix given with good result. : trached. 2.1l of free water deficit, corrected with d5w and decreased na on tpn. received lasix 20 and 2.2l negative. ngt placed. : continued tpn with low na and started d5w@50. lasix 20 . : stopped all antibiotics, holding diuretics. d/c'd d5w. rij with some erythema - watching. labetalol q6 w/ hold parameters : on lasix gtt (goal 500cc-1l). hypernatremia improving. echo ordered to evaluate fluid status per cardiology. :continued tpn, lasix gtt for goal of 1 l negative. off lasix gtt as pt diuresing well. 10:4: cardiac echo indicates slight improvement in rv function (with slight worsening of mr). : fentanyl replaced by dilaudid for primary pain med. vanco started. gtube clamped. : patient autodiuresing, lasix gtt stopped. plastics bedside debridement with ketamine for anesthesia. prealbumin came back 7 : vac changed. lle duplex incomplete (pt non-compliant). vanc dose held for elevated trough. : tolerated trach mask and changed to pmv so that she can speak, eval'd by s&s. : continued vanc per id recs. : vac changed with plastics wound change. heparin in tpn (sqh stopped). anxiety during day given 1 mg versed. psych consult for agitation. : face wound dressing changed with versed/ketamine. increased ativan dose to 0.25 q6h for increased agitation/anxiety. : b/l u/s w/ no dvt. psych states pt delirious & will follow. recommended changing ativan w/ haldol (or zyprexa). changed labetolol to metoprolol. : added haldol instead of ativan. to or for abdominal graft (stsg from l thigh) - tolerated very well. : picc placed by ir. r ij removed (site indurated w/ superficial hematoma). a-line removed. received 20 lasix in pm and was -300 for the day and -300 overnight. did not need haldol overnight. : dressing changes with dilaudid (d/c'ed ketamine/fentanyl). vanc trough 20, repeating in am per primary team. : vanc trough 22, holding am vanc dose on . transferred to floor from icu. : transfused 1 unit prbc for hct 25.8. : failed swallow eval (aspirated thins, spilled po): made npo. : to or by plastics for split thickness skin graft to l face. required 500 cc bolus x2 and 2 doses of 100 mcg ephedrine for hypotension to sbp 80s after metoprolol in pacu with hemodynamic stability since episode. : speech swallow eval with aspiration of thins and tolerance of small volumes of nectar-thickened liquids. : episodes of anxiety with crying. vanco held for high trough. feculent drainage around woundvac noted. : picc line discontinued for erythema/purulent drainage around site. culture subsequently positive for pseudomonas. : l upper extremity ultrasound negative for thrombus. : l face stsg bolster removed by plastics with viable graft underneath. : nausea/vomiting. fistulogram study inadequate. gtube replaced after dislodgement; started on tube feeds with vivonex. : started on imodium for leakage from woundvac w/o improvement in output. : geriatric consult obtained for delirium/hallucinations, recommending ct head for altered mental status. head ct normal. tf discontinued due to woundvac drainage and tpn increased to full strength. : urine and blood cultures obtained per geriatrics recs. started on cipro empirically for positive ua. blood from picc subsequently positive for coag neg stap in bottles and urine positive for citrobacter, klebsiella, and enterococcus. : started on vancomycin for positive blood culture (as above). : tracheostomy tube downsized to #6. patient self-discontinued picc. venous access team unable to replace picc; scheduled for ir picc placement after weekend. urine culture obtained: subsequently positive for enterococcus and pseudomonas. : restarted on tube feeds to maintain nutrition while no access for tpn. increased output from woundvac and drain noted. : tube feeds stopped due to vomiting. : picc replaced and tpn started. sensitivities back on urine cultures: vancomycin-resistant enterococcus and pseudomonas sensitive only to ceftazidime. cipro and vancomycin discontinued. started on daptomycin for vre, ceftazidime for pseudomonas, and bactrim for citrobacter. vac changed demonstrating good healing of wound. attempted to self-discontinue picc but picc tip in good position on cxr. : pseudomonas cultured from urine. blood culture neg. tracheostomy successfully decannulated. : swallow eval: okay for thin liquids and pureed solids. patient fell while sitting on edge of bed and needed assistance to be replaced in bed. c/o left ankle and sacral/coccygeal pain. rays of these areas obtained, which were negative. did not c/o hitting head and neuro exam grossly wnl, but given unreliable neuro exam, head ct obtained, which was negative for intracranial process. tachycardic to 110-120s and hypotensive to 80s/40s but asymptomatic. responded to 500 cc bolus. blood cultures negative. urine mixed c/w fecal contamination. stim test wnl (cortisol 25.5/29.2). . vac removed due to skin irritation and replaced with dry dressing and drain in fistula, with improvement in skin erythema. tachycardic to 130s and hypotensive to 80s/40s, which responded to 500 ml bolus and 1 u prbc (hct 25.3 to 28.1 post-transfusion). urine culture demonstrated 10-100k pseudomonas with intermediate sensitivity to ceftazidime. : daptomycin and bactrim discontinued. ceftazidime continued for urine pseudomonas. : infection disease consulted, recommending continuation of ceftazidime at higher dose for 14 days from negative urine culture of . : cardiac surgery in to evaluate 1cm erythematous, fluctuant sternal area. i&d with damp ns to dry gauze dressing (edge of 2x2). 5-10 cc of bloody, non-purulent fluid expressed. wound shallow and granulating. no need for chest ct at this time. physical therapy consult was obtained upon transferring out of sicu. initially, she was bed bound requiring lifting. at time of discharge strength had improved to allow for 2 person assisted transfer. rehab was recommended. a bed was available at rehab. she is transferring there today. medications on admission: 1. insulin sliding scale 2. simvastatin 20 mg daily 3. carvedilol 25 mg 4. aspirin 325 mg daily 5. acetaminophen prn 6. miconazole qid 7. ibuprofen prn 8. loperamide 2 qid prn diarrhea 9. lorazepam 0.5 mg prn anxiety 10. heparin 5000 units tid 11. diltiazem 30 mg qid 12. diphenhydramine 12.5prn, kcl 20 meq discharge medications: 1. insulin regular human 100 unit/ml solution sig: follow printed sliding scale injection four times a day. 2. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 3. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours). 5. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for skin irritation. 6. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 7. heparin flush (10 units/ml) 1 ml iv prn line flush temporary central access-floor: flush with 10 ml normal saline followed by heparin as above daily and prn. 8. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 9. haloperidol lactate 5 mg/ml solution sig: 0.25 mg injection q6h (every 6 hours) as needed for agitation: monitor qt interval. 10. ceftazidime 1 gram recon soln sig: two (2) recon soln injection every eight (8) hours for 1 weeks: uti started continue until . 11. outpatient lab work weekly labs: cbc, chem 10, ast, alt, alk phos, t.bili, albummin, pt/inr please fax to dr. office 12. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po daily (daily). 13. acetaminophen 650 mg/20.3 ml solution sig: one (1) dose po q6h (every 6 hours) as needed for pain. 14. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 15. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 16. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 17. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 18. tpn (as ordered per printed req) discharge disposition: extended care facility: for the aged - macu discharge diagnosis: h/o mi with rvad c/b sbo obstruction sb resection, multiple washouts enterocutaneous fistula s/p stsg to abd wound from left thigh left facial cellulitis/wound s/p ftsg from left chest occipital deculbitus uti, klebiella, enterococcus, citrobacter, pseudomonas (esbl) delerium discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. (see pt notes) discharge instructions: you will be transferring to rehab. please call dr. office if you have any of the following warning signs: fever, chills, nausea, vomiting, increased fistula output, abdominal wound has redness/bleeding/purulence, or left face wound has redness/drainage/bleeding followup instructions: provider: , md phone: date/time: 10:20 . medical office building call , md (cardiac sugeon) to schedule f/u in 1 week procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other partial resection of small intestine temporary tracheostomy other skin graft to other sites closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus attachment of pedicle or flap graft to other sites other lysis of peritoneal adhesions reopening of recent laparotomy site reopening of recent laparotomy site reopening of recent laparotomy site small-to-small intestinal anastomosis full-thickness skin graft to other sites central venous catheter placement with guidance central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified other postoperative infection urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site acute kidney failure, unspecified unspecified septicemia severe sepsis other and unspecified hyperlipidemia septic shock pressure ulcer, other site old myocardial infarction other and unspecified infection due to central venous catheter ventilator associated pneumonia acute vascular insufficiency of intestine migraine, unspecified, without mention of intractable migraine without mention of status migrainosus delirium due to conditions classified elsewhere pressure ulcer, stage iv fistula of intestine, excluding rectum and anus intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) attention to gastrostomy 

Answer: The patient is high likely exposed to