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: vancomycin attending: chief complaint: increased drooling, facial twitching major surgical or invasive procedure: left subclavian central line placement history of present illness: 76 y/o with pmh significant for htn, cad, dm, dementia(baseline a +o x 3, w/ expressive dysphasia to cva), , l mca stroke, chf and other medical problems who presents with w/ two days of right facial twitching, one day of increased drooling (noted at dinner time today), and worsening of normally mild right facial droop and slurred speech while at her nursing home. the nurse noted a concerned look on her face, though she remained alert and aware of the situation. her words were also unclear. the nurse at the nursing facility called ems. . of note, she also experience increased shortness of breath over the past week. this was felt to be chf. at , her md started to diurese her w/ lasix. her wt improved from 266 to 253 over the week. denies cp or n/v/d. past medical history: htn dyslipidemia dm ( mechanical valve) cad. s/p cardiac cath in and has been on plavix since then. unclear if stent was placed at that time. diastolic dysfunction ef >55%, 2+tr, moderate pasp cva left mca and with expressive aphasia dementia, oriented to person, place, time, can read watch recognizes son, has evidence of small vessel infarcts on ct h/o seizures after stroke on dilantin until late 80's pvd with amputations of three toes on right foot h/o r heel osteo h/o esophageal ulcers depression gallstones spinal stenosis h/o pulmonary sarcoid h/o pbc h/o c diff h/o vre urinary infection h/o decubitus ulcer followed at by dr. hypothyroidism social history: lives at rehab, has two son's who are very supportive and involved in her care. family history: h/o of pe x2 in son, no history of seizures, but son with heart disease physical exam: t: 96.2 bp: 138/53 p: 92 rr: 23 o2 sat: mid 90s on 3l nc general: overweight, mild respiratory distress, afebrile during some of exam, . heent: anicteric, mmm without lesions, op clear neck: supple, no lad, no carotid bruits, no thyromegaly cv: slighty tachy mechanical valve sound resp: tight diffuse wheezing and crackes abd: +bs soft/nt/nd ext: r foot is in bandages with several toes amputated, +2 edema skin: no rashes, petechiae neuro: r face twitching during exam but resolved spontaenously, otherwise cn ii-xii intact, r facial droop, dysarhric, motor, sensory and reflexes intact pertinent results: admission labs: wbc 10.6 with 80% n 0 bands 11%l hct 34.6 plt 184 chem: d-dimer 435, probnp 4461 ck 112 mb 5 trop 0.04 (baseline creat 1.7 (baseline ), bun 48 ag = 11 serum tox and urine tox negative tsh 6.6 free t4 7.8 . ekg 8:23:34 pm probable atrial fibrillation indeterminate frontal qrs axis intraventricular conduction defect low r(v2-v4) probably due to right ventricular hypertrophy inferior t wave changes are nonspecific repolarization changes may be partly due to rhythm baseline artifact precludes accurate interpretation of rhythm but suspect accelerated idioventricular rhythm, cannot rule out"regular" atrial fibrillation since previous tracing of left anterior fascicular block resolved . cxr: patient is post-median sternotomy. there is cardiomegaly, unchanged. mediastinal contours are unchanged, with calcification of the aorta. there is persistent elevation of the right hemidiaphragm. no consolidation or pulmonary edema in the lungs. no definite pleural effusion. . non-contrast head ct: there is no evidence of acute intracranial hemorrhage or shift of normally midline structures. the ventricles and cisterns are normal. there is encephalomalacia of portions of the left frontal, parietal and temporal lobes, consistent with prior infarction. the -white differentiation is preserved. visualized paranasal sinuses and mastoid air cells are clear. osseous and soft tissue structures are unremarkable. impression: no evidence of acute intracranial hemorrhage. chronic infarction in the left mca distribution. mri: large chronic left middle cerebral artery territory stroke. no enhancing mass lesions or other acute intracranial pathology identified. microbiology: 12:30 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci in pairs. in chains and. in clusters. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. moderate 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 _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ =>16 r levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ <=1 s 12:20 pm blood culture site: a line radial. aerobic bottle (final ): reported by phone to at 14:20pm on - cc6d. staphylococcus, coagulase negative. of two colonial morphologies. isolated from one set only sensitivities performed on request.. anaerobic bottle (pending): ... : ct: impression: 1. large left thigh hematoma, involving the sartorius and rectus femoris muscles. . 2. hazy appearance of the subcutaneous fat possibly also representing a small hematoma along the left lower chest/upper abdominal wall. . 3. anasarca. . ct: impression: 1. again seen is a soft tissue fluid collection adjacent to the left hip, consistent with the hematoma noted on prior study. additionally, there is a new hematoma within the right rectus muscle, measuring 7.7 x 6.2 cm, and a tiny focus of hemorrhage within the left rectus muscle, both at the level of the sacrum. 2. bilateral pleural effusions, greater on the right, unchanged from prior study. 3. there is asymmetric enlargement of the left psoas muscle. this is of uncertain etiology, though this is unchanged from prior studies dating back to . brief hospital course: in brief: 76 year old woman with mmp including old mca stroke presents with right simple partial seizure and respiratory distress, extensive hospital course complicated by tracheostomy tube, ventilator associated pneumonia and spontaneous bleeds in light of anticoagulation for . . in the ed she was evaluated by neurology and found to be having multiple brief eposides of facial twitching that lasted about 30 seconds, but she was able to follow commands during this time and her speech was more dysarthric than usual. between episodes, pt is alert, following commands,with r facial droop, still able to close r eye, and with slightly dysarthric speech. speech is much more dysarthric during the events. . she was given ativan 2 mg iv and loaded with dilantin 20mg./kg on tele to watch for hypoptension and arrythmias. she was noted to be in respiratory distress on 5 liters by nasal cannula, and she was initially considered for micu admission w/ neuro consult but she improved to 3l nc after nebs, lasix 80 x 1 and brief period of nitro gtt, which was stopped b/c of hypotension. she was also given levofloxacin for presumed uti and urine cx was also sent ; she was reloaded on dilantin with 1500 and again with 500 at 1 pm. despite this, she continues to seize every 10 minutes. subsequently, the micu was called because the patient was desatting and gurgling with worsened mental status. of note, the patient's bnp was found to be 4461 and her troponin was noted to be 0.05 which is at her baseline considering her renal failure. patient was subsequently intubated. of note, at baseline - pt is able to carry on basic conversation, walks with help, feeds self, knows and socializes with the staff at home. . # simple partial seizures: per son, patient has not seized in 20 years. she had been treated with dilantin in the past. we initially treated her with dilantin. depakote and keppra were later added on, but untimately she was treated with a single (keppra 1000mg qd), with good control of her seizures. workup revealed no mass lesion or new stroke. eeg showed no evidence of grand mal seizures. patient continued to be assymptomatic on keppra for the duration of her stay until . pt did not show any focal neurological deficits. . # altered mental status: was off baseline, has baseline aphasia. the possibility of her returning to her baseline mental status is unclear given a two-month icu stay with multiple psychotropic medicines. it is likely she will require weeks to clear a toxic-metabolic encephalopathy. . # unresponsiveness: she was slow to regain respnsiveness after sedation weaned down post intubation. head ct was again negative for new bleed. toxic metabolic workup unrevealing. patient slowly regained neurological function untitl she was back to baseline. patient was subsequently sedated while on the respirator. she remained on fentanyl drip and versed drip as she was visible uncomfortable with grimace during her care at the icu. during sedation wean periods patient's functional and responsiveness status did not change or increase significantly except for more frequent grimaces that were interpreted to be signs of discomfort. her sedation was weaned off prior to discharge to rehab. she was treated with a fentanyl patch of 25 mcg/hr and with fentanyl boluses prn. her mental status at the time of transfer to discharge was minimal. she only grimaces to pain no other clear responses. . # respiratory failure: initially intubated for airway protection and aspirtation risk. she also has had episodes of apnea. she has evidence of right elevated hemidiaphragm on cxr, perhaps secondary to ligation of phrenic nerve during sternotomy. she was treated with nebulizer combivent for wheeziness. one attempt at extubation on failed secondary to stridor/worry of laryngeal edema. she was reintubated and started on a short course of prednisone. patient subsequently underwent tracheostomy. she continued to have great oxygenation while on the ventilator. patient required persistant ac support, however after aggressive diuresis with cvvh as described below, she is tolerating ps well. patient eventually was placed back on ac after an episode of tachypnea and aggitation. patient subsequently had volume overload and pna complicating her pulmonary issues. she was continued on mdis to maximize her pulmonary function. she was then weaned to pressure support with a pressure setting of 15 and peep of 8 prior to discharge. it would be our plan to continue with psv weaning. . # chf exacerbation: she has h/o diastolic dysfunction. dry weight is 180 per son. echo showed ef 55%. followed previously by dr. at but has not been seen by cardiology in a while. unknown precipitant to the exacerbation but per son, she started wheezing 2 weeks ago. ruled out for mi. intermittant diuresis with lasix. treated with beta blocker and ace inh (held during concern for airway edema). echo on showed moderately dilated left and right atrium, mild symmetric left ventricular hypertrophy, questionable mildl depressed lv function (estimated ejection fraction ?50%), mild to moderate (+) mitral regurgitation, moderate tricuspid regurgitation, mild pulmonary artery systolic hypertension. patient continued to be grossly volume overload. cardiology and renal service were consulted and patient was started on cvvh with a goal of returning the patient to her dry weight while diuresing 30 l. patient continued to tolerate the diuresis well. her edema did improve after cvvh edema (+1 pitting at lower extremities). patient however by that point was requiring levophed to support her pressures, likely in part secondary to adrenal insufficiency. her levophed was weaned once the steroids were switched to iv. her cxr showed only mild improvement in her edema. it was determined that she was no longer a cvvh candidate. she was treated with lasix and metalazone prn for fluid overload. at the time of transfer to rehab she was on 200mg lasix and metalazone. . # bp/hypotension: patient had multiple episodes of hypotension while in the micu. ddx included acute blood loss into l thigh/rectus abdominus, vs infection/sepsis vs cardiogenic. cvp elevated although patient +30l during her stay, no ekg changes or ce elevations to suggest cardiac etiology. patient was treated for pna with abx. her hct was also closely followed and her blood products were repleted. patient had known spontaneous bleeding into r sided rectus abdominus x 2 around the sacral area and also l thigh bleed. patient was resuscitated with multiple blood products and ivfs to prevent hypotension. patient also required intermittent doses of levophed to keep her bp elevated during cvvh. her bp was monitored through an a-line. patient continues to require levophed for her bp support. she has been treated on an extensive course of meropenem/levoquin and vanco well past the course originally designated for her known cultures of mrsa sputum on and enterobacter in her sputum on . the antibiotics were continued due to persistant and increasing levophed requirement and leukocytosis. patient was also treated with several times for adrenal insufficiency and a repeat am cortisol was only 15.6 on . patient was subsequently started on high dose steroids. she was weaned off all pressors. she was placed on solumedrol for continued steroid support based upon her adrenal insufficiency. on transfer to rehab she is on solumedrol 20mg tid which should be weaned slowly over the next several weeks-months. she should be re-evaluated for adrenal insuffiency at that time. . # mrsa and enterobacter pna. patient with persistent leukocytosis and bandemia. rul pna on that persists. mrsa on sputum & enterobacter on sputum. patient initialy scheduled for 2 week meropenem and levo - 14 days) for enterobacter but continue for persistant leukocytosis. patient was also continued on empiric vancomycin for empiric line/hd coveragte. central lines were resited multiple times. on the vancomycin was discontinued after 3 weeks. on tranfer to rehab she will require continued meropenem and levo for a full 6 week course. . # cad: patient never had active chest pain. troponin mildly elevated upon admision but has been elevated in the past and continued to trend down. her ck-mb remained flat. patient was initially continued on her plavix, beta blocker, zocor. her bb was d/c in light of hypotension. her plavix was d/c after her second spontaneous bleeding episode involving l thigh bleed. patient ekg did not show any new ischemic changes. in the meantime patient was continued on heparin gtt for her . . # rate - afib with brief intermittent rvr. etiology: likely sepsis vs. hypovolemia vs. electrolyte abnormalities vs. hypercarbia. patient's rvr was controlled with amiodarone. in the meantime she was continued on heparin gtt for her . . # : held coumadin as inr supratherapeutic on admission. started on heparin drip for anticoagulation, with plan to transition back to coumadin. after her spontaneous bleeding episodes she was kept on a tight ptt scale of 40-60. . # uti: h/o levo-resistent uti in that required ctx, treated with ceftriaxone until sensitivities showed cipro effective so continued on cipro only for seven day course. repeat u/a and urine culture after treatment were negative for infection. . # arf: elevated cr to 1.9 which returned closer to baseline with fluids (1.3), likely prerenal based on her urine lytes. patient underwent a week long course of cvvh for removal of fluid that she tolerated well with support of levophed. patient's subsequent baseline appears to be at 1.9-2.0 with hypotension requiring pressors, chronic dm, htn playing a role. renal service didn't believe hemodialysis was indicated giving the grim condition of the patient. she is currently on lasix and metolazone for continued diuresis. . # dm: we continued her usual regimen of nph 6qam and 8qpm with sliding scale, titrated to fingersticks of 80-100, but then put her on an insulin drip on ce prednisone was started. patient was subsequently transition back to nph insulin based upon a high insulin drip requirement she was started on nph 25 with sliding scale coverage. . # anemia: iron studies normal and b12 and folate wnl. patient had intermittent blood loss into her spontaneous bleed in rectus abdominus x 2 and also l thigh requiring aggressive prbc resuscitation. vascular surgery was involved but since patient was adequately resuscitated with cessation of blood requirements after 24-48 hours, no intervention was awarranted. patient's hct was kept >28. . # s/p old stroke: we continued her aspirin and plavix. plavix was d/c due to persistant spontaneous hemotomas as described above. . # hypothyroidism: we continued her home dose of levothyroxine. . # gerd: she has h/o gib requiring hospitalization. treated with lansoprazole per ngt/po 30 qd. . # h/o primary biliary cirrhosis and gallstones: stable. we continued ursodiol . # h/o depression and post partum psychosis: - held risperdone and prozac given unresponsiveness and desire to decrease mediaction interactions. . # healthcare decision: multiple meetings were held with the family with a variety of attendings, the hospitals ethics support service and leagal staff. some of the care team at times felt the sons hopes of recovery were not realistic and were uncomfortable in providing care that they felt was just hurting the patient. my most recent discussions have focused on explaining ms. multi-organ system failure and her poor overall prognosis and assuring them that if it was in fact the patients wish to persue continued aggressive care, we would do so. they understand her high risk for nosocomial disease (vent associated pneumonia, uti, line infection, skin breakdown etc) and still wish to have her sedation lightened so they can communicate with her. i explained that as long as she is not experiencing pain, that is a reasonable goal. # communication: son who is also her health care proxy . # pcp: . at rehab medications on admission: lasix 100 daily (increase from 80 on ) plavix 70 daily fluoxetine 20 daily duoneb risperdal 1 qhs protonix 40 daily metoprolol 12.5 pantoprazole simvastatin 10 qhs senna ursodial 600 tylenol prn riss + nph 6qam and 8qpm lisinopril 2.5 daily levothyroxine 50 daily glyburide 2.5 daily maalox prn discharge medications: 1. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 6. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 9. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 10. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 11. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed for constipation. 12. artificial tear ointment 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 13. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 14. metolazone 5 mg tablet sig: two (2) tablet po daily (daily): give half hour prior to lasix. 15. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed. 16. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation qid (4 times a day). 17. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane tid (3 times a day) as needed. 18. insulin nph human recomb 100 unit/ml cartridge sig: twenty five (25) units subcutaneous twice a day: at breakfast and bedtime. 19. fentanyl 25 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 20. heparin (porcine) in d5w 100 unit/ml parenteral solution sig: 1500 (1500) units/hr intravenous asdir (as directed): adjust for target ptt 40-60 seconds. continue until coumadin therapeutic. 21. heparin lock flush (porcine) 100 unit/ml syringe sig: ten (10) ml intravenous daily (daily) as needed: to each lumen qd and prn. 22. levofloxacin in d5w 250 mg/50 ml piggyback sig: one (1) intravenous q48h (every 48 hours) for 3 weeks: continue until . 23. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours) for 3 weeks: continue until . 24. furosemide 10 mg/ml solution sig: two hundred (200) mg injection (2 times a day): please give 30 minutes after metolazone. 25. fentanyl citrate (pf) 0.05 mg/ml solution sig: 25-100 mcg injection q2h (every 2 hours) as needed. 26. methylprednisolone sodium succ 1,000 mg/8 ml recon soln sig: twenty (20) mg recon soln injection q8h (every 8 hours). discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: 1. seizures 2. respiratory failure 3. shock 4. adrenal insufficiency 5. left thigh bleed 6. mrsa and enterobacter pna 7. chf/volume overload 8. renal failure 9. /st. jude's valve 10. hypothyroidism discharge condition: stable, responsive to pain only, withdraws, does not respond to voice or other stimuli. discharge instructions: continue to monitor bp, cbc, inr, ptt. will need to have coumadin restarted and titrated to inr goal . continue lasix prn to keep fluid status even. continue vent weaning. titrate insulin to fs 60-120. continue meropenem and levofloxacin for total of 6 week course, complete on . titrate down steroids. followup instructions: as above procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube arterial catheterization temporary tracheostomy percutaneous [endoscopic] gastrojejunostomy bronchoscopy through artificial stoma transfusion of packed cells replacement of tracheostomy tube transfusion of other serum video and radio-telemetered electroencephalographic monitoring diagnoses: nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere abnormal coagulation profile coronary atherosclerosis of native coronary artery pneumonia due to other gram-negative bacteria tobacco use disorder unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation infection with microorganisms resistant to penicillins other convulsions other persistent mental disorders due to conditions classified elsewhere hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease heart valve replaced by other means other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure hypotension, unspecified methicillin susceptible pneumonia due to staphylococcus aureus pressure ulcer, lower back accidents occurring in other specified places combined systolic and diastolic heart failure, unspecified diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled hemorrhage, unspecified ulcer of esophagus without bleeding other tracheostomy complications edema abnormal involuntary movements shock, unspecified cerebral artery occlusion, unspecified without mention of cerebral infarction feeding difficulties and mismanagement 

Answer: The patient is high likely exposed to