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: tachypnea major surgical or invasive procedure: none history of present illness: 81 year-old female with cad s/p cabg x 3 and mitral valve repair (bioprosthetic) at , chf, cad, prior c. difficile infection admitted from house rehab with increasing oxygen requirement and tachpnea. per rehab call-in, baseline oxygen saturation mid-90s on 2l nasal canula; takes torsemide 50mg po daily. today noted to have increased dyspnea at rest with increased oxygen requirement (mid-90s oxygen saturation on 5l nc); minimal improvement with nebulizer treatments, additional torsemide 20mg po daily. cxr at rehab showed "moderate congestion." . of note, she recently completed a long, slow taper of vancomycin po for c. difficile infection. she continues on cholestyramine. has had some loose stools today, but staff note dtr has been giving her mom at times. she was also recently discharged on after an admission for chf. since then, she has seen her cardiologist who changed her lasix to torsemide 100mg daily (of note rehab call-in reported 50mg daily). . in the ed, 100.7 89 122/91 32 100%. physical examination noted for tachypnea, significant peripheral edema. laboratory data significant for creatinine 1.5, wbc 8.5 with left shift, first set cardiac markers with normal limits. abg 7.45/44/96. ua nitrite positive and with many bacteria. lactate 2.2. cxr 1v with fluid overload, no clear infiltrate. ekg reportedly unremarkable. blood cultures, urine culture sent. received lasix 40mg iv, nitro gtt. was briefly on bipap, now doing well off bipap (stopped approximately 1 hour ago). sbp dropped to 80s, nitro gtt was stopped and bp improved. on transfer to micu, 100% on nrb. pt also given vanc, clindamycin and and levoquin. . on arrival to the ccu, fs was 40. she received 1amp d50. she was not communicative with phone interpreter. patient frequently taking off bipap mask. . patient unable to answer review of systems. past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: -cabg: s/p cabg x 3 and mitral valve repair (bioprosthetic) at (/) cath showed a 3-vessel coronary artery disease. lad had 60% mid vessel stenosis and 60% stenosis of a small diagonal. her left circumflex had 90% ostial om 1 stenosis and the mid rca was occluded with left to right collaterals. her resting hemodynamics demonstrated elevated right and left sided filling pressures with a mean ra pressure of 16 mmhg, rvedp of 19 mmhg, mean pulmonary capillary wedge pressure of 24 mmhg, and a pcwv of 33 mmhg, and an lvedp of 22 mmhg. -percutaneous coronary interventions: cath see above -pacing/icd: none 3. other past medical history: . #. coronary artery disease - s/p cabg x 3 and mitral valve repair (bioprosthetic) at (/) post-operative course complicated by prolonged mechanical ventilation requiring tracheostomy and peg tube placement, c. diff colitis, and upper gi bleed #. history of type b thrombosed aortic dissection (seen on chest cta ) # postoperative af, unable to tolerate warfarin (gib). #. h/o recurrent clostridium difficile colitis x8-9 times, treated with flagyl po, flagyl iv, vanco po with taper in past--usually in setting of abx for utis #. h/o upper gi bleed #. gallstones diagnosed 30 years prior. #. type ii diabetes #. hypertension. #. status post hysterectomy. #. history of benign mastitis and lumpectomy. #. history of paroxysmal atrial fibrillation not on ac (?) #. t11 vertebral compression fx () #. diastolic chf (ef > 65% ) #. history of multiple urinary tract infections after spending 1.5 months () at icu -> for vented unit -> rehab ( where the peg was removed) -> home where she developed cdiff colitis -> -> macu in ()-> ( - ) -> home for 1.5 months with husband and -> lower back pain and slid off bed-> wound in leg -> -> macu -> (admitted ). social history: home: -speaking only. lived with husband prior to heart surgery. had prolonged hospitalization and rehab course after cabg and mvr in . at rehab after most recent discharge. see outline below. tobacco: never smoked. occupation: retired physician : denies drugs: denies very hard of hearing and her husband takes her hearing aides home at night. prior to her heart surgery she walked without a walker or cane. prior to coming in in at home she was able to walk with a walker outside with her husband and climb 7 steps. at baseline she did not have noticeable memory deficits. family history: she is an only child. mother died of heart disease in her 70s. father died in the war. physical exam: vs: t= 98.1 bp=109/56 hr=84 rr=89 o2 sat= 99% fio2 35% general: elderly patient laying in bed, removing bipap mask frequently. not answering questions with phone interpreter though shakes her head to questions. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp elevated to ear lobe. cardiac: pmi laterally displaced. irregular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp labored with accessory muscle use. lung sounds notable for rhonchi and reduced breath sounds at bases. abdomen: soft. patient appears uncomfortable with palpation, though in general appears to be uncomfortable with palpation of any part of her body. no hsm. abd aorta not enlarged by palpation. no abdominial bruits. extremities: +3 edema to the thighs bilaterally. no femoral bruits. skin: venous ulcers on le bl wrapped with gauze. pulses: distal pulses difficult to appreciate given edema. pertinent results: 03:50pm pt-12.9 ptt-23.1 inr(pt)-1.1 03:50pm plt count-281 03:50pm neuts-86.4* lymphs-4.7* monos-7.5 eos-1.0 basos-0.4 03:50pm wbc-8.5 rbc-4.60 hgb-11.4* hct-37.1 mcv-81* mch-24.9* mchc-30.8* rdw-16.8* 03:50pm probnp-9626* 03:50pm ctropnt-<0.01 03:50pm estgfr-using this 03:50pm glucose-241* urea n-48* creat-1.5* sodium-136 potassium-4.5 chloride-94* total co2-30 anion gap-17 04:07pm type-art po2-96 pco2-44 ph-7.45 total co2-32* base xs-5 04:18pm urine hyaline-* 04:18pm urine rbc-0 wbc-0-2 bacteria-many yeast-none epi-0 04:18pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:18pm urine color-straw appear-clear sp -1.008 04:18pm urine uhold-hold 04:18pm urine hours-random 05:19pm lactate-2.2* 05:19pm comments-green top 11:41pm lactate-1.0 11:41pm type-art po2-63* pco2-46* ph-7.47* total co2-34* base xs-8 brief hospital course: summary 81 year-old female with chf, cad, prior c. difficile infection admitted with tachypnea and dyspnea with evidence of volume overload on exam and on cxr. she responded to aggressive diuresis but refused laboratories and had compounded by severe c.diff colitis. she also continued to chronically aspirate. micu course to patient was transferred to the micu from the ccu service through for altered mental status and hypotension. patient had not had labs for several days and was found to be in acute on chronic renal failure to cr of 3.7, which was likely from over agressive diuresis with torsemide. cr improved with gentle iv hydration from 2.6 to 1.7 whil in the micu. mental status improved with improved renal function. cdiff was managed with oral vancomycin 250 mg qid with flagyl 500 mg iv q8h, and patient was kept npo. surgery and id remained involved during this care. kub revealed colonic ileus, but patient continued to have stools per day and abdominal exam was benign. by problem. 1. diastolic heart failure, severe and acute on chronic on arrival to the ccu, patient was tachypneic and very short of breath. her symptoms were thought to be secondary to acute on chronic diastolic heart failure (elevated bnp and evidence of pulmonary edema on cxr). ecg notable for atrial flutter, exacerbating her heart failure symptoms. she was briefly placed on bipap, but became very agitated and removed the bipap. she was diuresed with lasix drip and given morphine. patient was volume overloaded on exam, with . she was initially diuresed with a lasix drip and metolazone. her creatine increased after diuresis and lasix drip was briedly held. she was subsequently started on 100mg po torsemide. this was complicated by (see below). she was ultimately discharged on alternating doses of 30 and 40mg of torsemide. we are tolerating a creatinine of , aiming toward 1.5. 2. patient over diuresed in the setting of refusing lab draws. this, in the setting of hypotension, prompted a brief micu transfer. it resolved with ivf. in the name of euvolemia, it was resolved to tolerate a creatinine of . 3. severe c. diff colitis patient had recently finished long vancomycin taper. po vanc was started prophylactically while she was treated for her uti using cipro. cholestyramine was held given patient's complaints of constipation on admission. this became markedly worse. she came under control with higher doses of po vanc and iv flagyl. on discharge she was kept on a taper of vanc po and later rifaximin. 4. aspiration comfort eating dnr/dni patient is known chronic aspirator. video swallow revealed aspiration. speech and swallow reccommended npo. patient has had peg in past, family recognized that patient prefers to eat for comfort and pleasure. patient allowed to eat and drink and made dnr/dni with no micu transfers. at the time of discharge, the family was considering a do-not-hospitalize policy. 5. atrial flutter admission ecg notable for atrial flutter. amiodarone was discontinued. she was continued on metoprolol 37.5mg tid and subsequently switched to metoprolol succinate 100mg daily. due to blood pressure limitations, her dose was titrated to safety. she was discharged on metoprolol 25 mg tid. patient not anticoagulated given significant history of gi bleed, though she was kept on aspirin 325mg. 6. cad patient has history of 3 vessel disease s/p multivessel cabg and mvr in . she denied any symptoms of chest pain. her ecg was without ischemic changes. her cardiac markers were elevated, in the setting of chf and renal insufficiency. she was continued on aspirin, metoprolol and simvastatin. 7. uti urine notable for ecoli sensitive to cipro. patient was febrile in the ed, but defervesced upon arrival. she was treated with cipro for her uti and started on vanc prophylactically given her significant history of c diff. this failed. the patient has asymptomatic bacteriuria. she should never be treated with cipro. she can receive cranberry juice. consider intravaginal estriol for treatment of atrophic vaginitis and therefore uti ppx. 8. hypoglycemia/diabetes: patient was hypoglycemic on arrival to the icu and responded well to 1 amp d50 with appropriate response to blood sugar. her insulin regimen was initially held and restarted at a lower dose of glargine 6u (previously on 10 u) once blood sugars stable. 9. hypothyroid: patient continued on her synthroid. tsh was checked and was within normal limits. . #. htn: metoprolol . #. hld: continued home statin. special notes 1. please check na, k, hco3, cr and bun every 3 days. this information is crucial to the management of her heart failure. it is appropriate and encouraged to keep her creatinine at 1-2 (~1.5) 2. physical therapy: please work on strength and stamina. keep out of bed for meals. 3. telemetry. patient in atrial fibrillation. tachycardia > 110 can be a sign of overdiuresis. 4. diuretics: a. weigh patient daily. if increase in > 3lb, must contact md and increase diuretic b. must tolerate creatinine between 1 and 2. effective diuresis causes mild renal failure. if creatinine > 2, then reduce torsemide dose. if cr < 1.3, then increase torsemide dose. consult with md. consider changing dose by 10 mg. c. patient is resistent to oral lasix 5. utis a. do not give patient antibiotics for uti unless positive that it is causing symptoms. cipro causes c.diff b. encourage cranberry juice consumption c. consider intravaginal estriol for atrophic vaginitis and prevention of bacteriuria 6. aspiration patient chronically aspirates. her family is aware of this. she was allowed to eat for comfort. 7. dnr/dni patient was made dnr/dni this hospitalization medications on admission: aspirin 81 mg/day amiodarone 200 mg/day synthroid 150 mcg/day (per rehab note) prilosec 20 mg/day spironolactone 12.5 mg/day lidocaine patch simvastatin 40 mg/day calcium 600 mg b.i.d., metoprolol 37.5 mg t.i.d. torsemide 50mg by mouth daily vancomycin 125 mg p.o. b.i.d. (completed) vitamin d colace iron 325 mg daily cholestyramine-sucrose 4 gram packet tid glargine insulin 10 units qhs (not on rehab list) humolog sliding scale insulin (not on rehab list) combivent calcium 500 + d 500 mg(1,250mg) -400 unit discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): on for 12 hours during day. 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for back pain. 4. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 6 days: last day is . 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 6. calcium 500 mg tablet sig: one (1) tablet po twice a day. 7. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet, chewable po once a day. 8. ferrousul 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 9. cholestyramine-aspartame 4 gram packet sig: one (1) packet po three times a day. 10. lantus 100 unit/ml solution sig: ten (10) units subcutaneous at bedtime. 11. levothyroxine 150 mcg tablet sig: one (1) tablet po once a day. 12. aspirin 325 mg tablet sig: one (1) tablet po once a day. 13. torsemide 20 mg tablet sig: 1.5-2 tablets po once a day: give 30mg and 40mg on alternating days. hold if cr > 2.0. if cr falls below 1.3, or patient short of breath, increase dose of torsemide. 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po three times a day. 15. xifaxan 200 mg tablet sig: two (2) tablet po twice a day for 2 weeks: start on and continue for 2 weeks. 16. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 17. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 18. olanzapine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for agitation. 19. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 20. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 21. outpatient lab work please check na, k, hco3, cr and bun every 3 days. 22. outpatient physical therapy please work on strength and stamina. keep out of bed for meals. 23. telemetry please monitor on telemetry. patient in atrial fibrillation. tachycardia > 110 can be a sign of overdiuresis. 24. diuretics 1. weigh patient daily. if increase in > 3lb, must contact md and increase diuretic 2. must tolerate creatinine between 1 and 2. effective diuresis causes mild renal failure. if creatinine > 2, then reduce torsemide dose. if cr < 1.3, then increase torsemide dose. consult with md. consider changing dose by 10 mg. 3. patient is resistent to oral lasix 25. utis 1. do not give patient antibiotics for uti unless positive that it is causing symptoms. cipro causes c.diff 2. encourage cranberry juice consumption 3. consider intravaginal estriol for atrophic vaginitis and prevention of bacteriuria 26. aspiration patient chronically aspirates. her family is aware of this. she was allowed to eat for comfort. 27. dnr/dni patient was made dnr/dni this hospitalization discharge disposition: extended care facility: - discharge diagnosis: acute on chronic diastolic congestive heart failure acute on chronic kidney disease urinary tract infection c-difficile infection chronic aspiration discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you had an episode of congestive heart failure and needed to receive medicine to take off the extra fluid. you need to weigh yourself every day and notify dr. if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. you were started on an antibiotic course for c-difficile infection. finally, you were found to aspirate or inhale food and water. it was decided to allow you the pleasure and comfort of eating and drinking despite the risk. medication changes: 1. increase aspirin to 325 mg 2. discontinue amiodarone and spironolactone 3. torsemide 30 mg daily 4. change metoprolol tartrate 5. vancomycin 125 mg every six hours until . 6. rifaximin three times daily for 2 weeks, starting 7. stop omeprazole . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: primary care: , date/time: please make an appt to see when you get out of rehabililtation. . cardiology: provider: , md phone: date/time: 11:20 . . pain clinic: provider: , md phone: date/time: 12:50 . department: pain management center when: tuesday at 12:50 pm with: , md building: one place (, ma) campus: off campus best parking: parking on site . gastroenterology: dr. -division of gastroenterology/gi east ,da-601 , phone: fax: please make an appt for 3-4 weeks. procedure: venous catheterization, not elsewhere classified diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation acute on chronic diastolic heart failure chronic kidney disease, unspecified diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled intestinal infection due to clostridium difficile paralytic ileus hypoxemia heart valve replaced by transplant hypertensive chronic kidney disease, benign, with chronic kidney disease stage i through stage iv, or unspecified postmenopausal atrophic vaginitis 

Answer: The patient is high likely exposed to