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: heparin agents / cefepime / vancomycin attending: chief complaint: transfer from for nstemi, cardiogenic and septic shock major surgical or invasive procedure: cardiac catheterization insertion of central venous catheter history of present illness: hpi: 58 male with h/o cad s/p mi, dm2, htn, atrial fibrillation, morbid obesity presented to hospital with 2-3 days of productive cough and hemoptysis. he was found to be in significant respiratory distress, and bipap was initiated. he then became agitated and confused, and he required intubation with abg of 7.23/61/66. he then became hypotensive and had decreased urine output (despite agressive diuresis). he was eventually started on levophed and neosynephrine, with propofol for sedation. his cxr was read as an infiltrate; his bnp was >1100; his cardiac enzymes were elevated, and there were no st elevations on his ecg. he was given , plavix 300, mucomyst, and moxifloxacin x 1, and transferred to for presumed cardiogenic shock, nstemi, and emergent catheterization. . ros: per his family, he has had a productive cough for several weeks, and increasing dyspnea on exertion, orthopnea, and pnd. he did not complain of any chest pain, fevers, chills, nausea, vomiting, or urinary symptoms. he has had chronic diarrhea since starting metformin (which has been stopped), and may have been worse recently. he also complained of intermittent headaches. . on arrival to he was taken emergently to the cardiac catheterization lab, where he was found to have three vessel disease (lm 40-50%; lad 95% prox/mid; lcx subtotal plaque; rca mid 60% and distal 80%. there were no interventions done on the coronary arteries (felt that the lcx occlusion was old). his pressures were: ra 29; rv 86/12; pa 74/40; pcw 28; co 8.7; ci 2.9. a balloon pump was inserted. . on arrival to the ccu he was intubated, sedated, with swan ganz catheter in his right groin, balloon pump through his left groin. past medical history: cad (fixed anterolateral defect) htn atrial fibrillation, chronic dm-2 obesity osa pulmonary hypertension (on home cpap) social history: denies tobacco; occasional etoh; he has a girlfriend, no children. he works as a 5th grade teacher family history: father: h/o malaria; died of mi at age 49 mother: cabg in 70s physical exam: vs- 100.7 112 122/86 100% on ac 600/18, peep 5, 100% fio2 gen- sedated, intubated, not following commands; morbidly obese heent- mmm, anicteric neck- obese, could not assess jvp; no carotid bruits cv- irreg irreg, tachy, no s3, no m/r/g appreciated chest- clear anteriorlly, decreased at bases abd- obese, soft, pos bs ext- no c/c, 1+ edema bilaterally. shiny skin, venous insufficiecy changes neuro- sedated skin- erythema lesions beneath breasts (l>r) pertinent results: discharge labs: . . . admission labs: . 11:45am blood wbc-23.9* rbc-4.42* hgb-13.2* hct-39.6* mcv-90 mch-29.9 mchc-33.3 rdw-15.3 plt ct-190 11:45am blood neuts-60 bands-33* lymphs-4* monos-1* eos-0 baso-0 atyps-0 metas-1* myelos-1* 11:45am blood pt-35.2* ptt-37.6* inr(pt)-3.8* 11:45am blood glucose-37* urean-51* creat-3.0* na-136 k-4.6 cl-100 hco3-26 angap-15 11:45am blood glucose-37* urean-51* creat-3.0* na-136 k-4.6 cl-100 hco3-26 angap-15 08:35pm blood glucose-141* urean-52* creat-3.0* na-136 k-4.8 cl-100 hco3-20* angap-21* 05:04am blood glucose-92 urean-55* creat-3.2* na-135 k-5.9* cl-99 hco3-20* angap-22* 11:45am blood alt-35 ast-117* ck(cpk)-874* alkphos-71 amylase-48 dirbili-0.6* 05:04am blood ck(cpk)-1465* 02:51pm blood ck(cpk)-328* 03:49am blood alt-84* ast-80* alkphos-88 amylase-85 totbili-1.7* 11:45am blood %hba1c-5.8 -done -done 08:35pm blood tsh-0.94 10:23am blood cortsol-30.6* 10:52am blood cortsol-42.9* 11:40am blood cortsol-44.0* 04:00pm blood type-art po2-126* pco2-60* ph-7.38 calhco3-37* base xs-8 06:19pm blood heparin dependent antibodies- positive . card cath: . comments: 1. selective coronary angiography of this right dominant system revealed three vessel disease. the lmca had an eccentric 50% distal plaque extending into the origin of the lcx. the lad was diffusely diseased throughout with a complex, uclerated 95% stenosis in the mid vessel with timi3 flow. the lcx was a severely diffusely diseased vessel that was subtotally occluded proximally. the rca was a dominant vessel with an ulcerated 60% stenosis in the mid vessel and an 80% stenosis in a diminutive rpl branch. 2. resting hemodunamics revealed severely elevated right and left sided filling pressures (mrap 27 mmhg, mpcw 38 mmhg). there was severe pulmonary arterial hypertension (mpap 50 mmhg). the cardiac index was normal (2.9 l/m/m2). 3. successful placement of a 40cc intraaortic balloon pump. final diagnosis: 1. three vessel coronary artery disease. 2. severely elevated right and left sided filling pressures. 3. severe pulmonary hypertension. 4. successful balloon pump placement. . tee: . conclusions: no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with hypokinesis of the anterior wall. the remainder of the walls contract well although the apex is not fully visualized (estimated ejection fraction ?45%). right ventricular chamber size and free wall motion are normal in suboptimal views. there are complex (>4mm) non-mobile atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. . impression: anterior wall hypokinesis with overall probably mildly depressed left ventricular systolic function (with iabp support). no significant valvular disease. complex, non-mobile atheroma in descending aorta. . initial cxr: . two radiographs of the chest demonstrates an endotracheal tube with its tip at the level of the clavicular heads. cardiac size is not well assessed secondary to portable technique, but there is probably mild cardiomegaly. there is a nasogastric tube present with its tip in the stomach. assessment of the pulmonary parenchyma is limited by patient rotation and position. no consolidation is evident. no pleural effusion is detected. trachea is midline. . impression: . satisfactory placement of endotracheal tube. . measurements: left ventricle - ejection fraction: 35% to 40% (nl >=55%) interpretation: findings: the patient was intubated and mechanically ventilated during the procedure. he was on 1 mg/hr iv of midazolam, and 25mcg/hr for sedation, which was continued during the procedure. the patient was receiving iabp support during the procedure. the descending thoracic aorta was not well visualized due to the presence of the iabp. . right atrium/interatrial septum: a catheter or pacing wire is seen in the ra. normal interatrial septum. no asd by 2d or color doppler. . left ventricle: mild symmetric lvh with normal cavity size. mild-moderate regional lv systolic dysfunction. . right ventricle: normal rv chamber size and free wall motion. . aorta: focal calcifications in aortic root. . aortic valve: mildly thickened aortic valve leaflets (3). no ar. . mitral valve: normal mitral valve leaflets with trivial mr. . tricuspid valve: normal tricuspid valve leaflets with trivial tr. . pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. physiologic (normal) pr. . pericardium: no pericardial effusion. . general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. no tee related complications. the rhythm appears to be atrial fibrillation. based on aha endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. results were reviewed with the cardiology fellow involved with the patient's care. echocardiographic results were reviewed with the houseofficer caring for the patient. an intra-aortic balloon pump was placed. the proximal balloon tip is positioned distal to the takeoff of the left subclavian. . conclusions: no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with hypokinesis of the anterior wall. the remainder of the walls contract well although the apex is not fully visualized (estimated ejection fraction ?45%). right ventricular chamber size and free wall motion are normal in suboptimal views. there are complex (>4mm) non-mobile atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. . impression: anterior wall hypokinesis with overall probably mildly depressed left ventricular systolic function (with iabp support). no significant valvular disease. complex, non-mobile atheroma in descending aorta. . based on aha endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . brief history: mr presents for coronary revascularization. he presented two weeks ago in shock presumed to be due to sepsis, with a possible contribution from chd. his angiogram at that time showed three vessel disease. since then he has been intubated and had difficulty in weaning off. he is also morbidly obese, has diabetes and af. he subsequently developed hit and has been treated with argatroban iv. his echocardiogram showed an ef of 40-45% with anterior hypokinesia. indications for catheterization: for pci procedure: left heart catheterization: was performed by percutaneous entry of the right femoral artery, using a 8 french xb lad 4.5 catheter, advanced to the ascending aorta through a 8 french introducing sheath. coronary angiography: was performed in multiple projections using a 8 french xb 4.5 lad guide and a 8 french jr4 guide catheter, with manual contrast injections. percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). percutaneous coronary revascularization of an additional vessel was performed using balloon angioplasty. percutaneous coronary revascularization of an additional vessel was performed using placement of drug-eluting stent(s). conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. **ptca results cx lad rca **baseline stenosis pre-ptca 100 90 70 **technique guiding cath 8f xb 4. 8f xb 4. 8f jr4 guidewires ptgi prowater prowater initial balloon (mm) 1.5 2 3.5 final balloon (mm) 2 3 3.5 # inflations 8 9 1 max pressure (psi) 180 300 270 **result stenosis post-ptca 0 0 dissection (0-4) 1 success? (y/n) y y y ptca comments: the angiogram showed a diffusely diseased proximal/mid lad with a 80-90% lesion through which the d1 arose. the cx was completely occluded woth collateralisation. the mid rca had an eccentric 60-70% lesion. we planned to treat these lesions using , and plavix prophylactically and starting with the cx. (he has a h/o hit) a 8f xb 4.5 guide provided adeqaute support. we then crossed in to the distal cx with a pt im wire with minimal difficulty and performed serial multiple dilations using a 1.5 x 09mm maveick and a 2.0 x 15mm voyager balloon at 9-12 atm. this resulted in timi iii flow, mild dissection and a 30% residual stenosis with no embolisation. . we then turned our attention to the lad. the lesion was crossed using a prowater wire with some difficulty and predilated with a 2.0 x 20mm (inflated up to 14-18atm) and a 2.5 x 20mm sprinter ( infalted up to atm) balloons from distal to proximal lesion. we then deployed a 2.5 x 28mm and a 3.0 x 18mm cypher stent at 20 atm and 18 atm from distal to proximal resepectively. this jailed the d1 causing a non flow limiting 70% lesions. the final angiogram showed timi iii flow, no residual stenosis, no dissection or embolisation in the stented segement. . we then turned our attention to the rca. a 8f jr 4 guide provided adequate support. a prowater wire crossed in to the distal vessel easily.we then directly deployed a 3.5 x 13mm cypher stent at 18 atm. the final angiogram showed timi iii flow with no residual stenosis, no dissection and no embolisation. the patient left the lab in a stable condition. technical factors: total time (lidocaine to test complete) = 1 hour 14 minutes. arterial time = 1 hour 8 minutes. fluoro time = 23 minutes. contrast: non-ionic low osmolar (isovue, optiray...), vol 320 ml premedications: cefazolin 1g anesthesia: 1% lidocaine subq. anticoagulation: heparin 0 units iv other medication: bolus 135 mg, drip 315 mg hr fentanyl 100 mctg plavix 600 mg midazolam 6 mg cardiac cath supplies used: .014 , pt , 300cm .014 , asahi prowater, 300 .014 , asahi prowater, 300 2.0 , maverick, 15 2.0 guidant, voyager 15 1.5 , maverick, 9 2.0 , sprinter, 20 2.5 , sprinter, 20 8f cordis, xblad 3.5 8f cordis, xblad 4.0 8f cordis, xblad 4.5 8f cordis, jr 4 sh 200cc mallincrodt, optiray 200cc 200cc mallincrodt, optiray 200cc 2.5 cordis, cypher rx, 28 3.0 cordis, cypher rx, 18 3.5 cordis, cypher otw, 13 comments: 1. the lcx total occlusion was angioplastied with a 1.5 x 09mm maverick and 2.0 x 15mm voyager balloons with lesion reduction from 100% to 30%. the final angiogram showed timi iii flow, 30% diffuse residual stenosis, mild dissection and no embolisation. (see ptca comments) . 2. the proximal lad lesion was predilated with a 2.0 x 20mm and a 2.5 x 20mm sprinter balloon and stented with a 2.5 x 28mm and a 3.0 x 18mm cypher stent in an overlapping manner with lesion reduction from 90% to 0%. the final angiogram showed timi iii flow with no residual stenosis in the stented segment with no dissection or embolisation. the jailed d1 had an ostial stenosis of 70% severity with no flow limitation. (see ptca comments) . 3. the mid rca lesion was directly stented with a 3.5 x 13mm cypher stent with lesion reduction from 70% to 0% the final angiogram showed timi iii flow with no dissection or embolisation. (see ptca comments) final diagnosis: 1. three vessel coronary artery disease. 2. mildly impaired ventricular function. 3. successful balloon angioplasty of the proximal lcx 4. successful stenting of the proximal lad 5. successful stenting of the mid rca . cxr: findings: there is stable cardiomegaly. pulmonary edema pattern seen on the prior radiographs is essentially unchanged. left retrocardiac opacity with obscuration of the hemidiaphragm is stable in appearance. impression: no significant change. brief hospital course: impression/plan: 58 morbidly obese male with h/o cad, htn, dm2, hypercholesterolemia presenting with hypotension/sepsis due to infection and cardiogenic, respiratory failure, fever, nstemi , acute renal failure now s/p trach/peg for osa/obesity/pulmonary hypertension, s/p lad desx2, rca - des, lcx s/p baloon on , being transfered for further pulmonary rehab. . hypotension: initially felt to be combination of septic and cardiogenic shock. patient was found to be with decreased cardiac index as well as elevated leukocytosis. cardiac index and output soon returned to . patient's iabp was discontinued. patient was also titrated offf levophed adn vasopressin over 3 days with maps > 60. for septic component patient presented with several weeks of diarrhea, cough and then hemoptysis thus pna was felt to be most likely course of infection. patient was empirically treated for vap, initially levo/azithro. his sputum on grew out mrsa and vanco was added. he remained febrile and antibiotics were switched to vanc/ctx/azithro, then vanc/cefepime, then switched to aztreonam/linezolid for suspected drug fever/rash, completing 10d course on . his rash improved and vanco and cefepime were deemed to be potential allergens. patient was also subsequent found to have c. diff () and was started on flagyl, he completed 14 day course on . patient was also found to be bacteremic after he grew out bcx on that showed mrsa. patient was treated with linezolid because of his presumed rash to vancomycin. he is to complete 14 day course. patient's sputum was also positive for mrsa with moderate growth which may be a chronic colonizer but 2 week course should be more than adequate for ventilator associated pneumonia and excellent lung penetration with linezolid. patient had his r scl line subsequently resited on . his lines were d/c upon discharge. he remained afebrile 48 hours prior to discharge. patient was also treated with a 7 day course of aztreonam that finished on . patient remained normotensive through the rest of the course and tolerated his beta blocker and his ace well. . atrial fib: patient with chronic history with persistent af. patient was initially started on amiodarone and digoxin for rate control. he was loaded and then switched to amiodarone po. he was also started on heparin drip for anticoagulation. patient was subsequently found to be thrombocytopenic and with + heparin antibody. his anticoagulation was switched to argatroban. his course was also complicated by bradycardic af to 30s without bp compromise. his digoxin and amiodarone were d/c and patient recovered to 60s. he was slowly restarted on low dose beta blocker and remained in 60s as his beta blocker was titrated up. patient was also restarted on coumadin with a goal inr of and he needs his coumadin dose to be adjusted based on weekly inrs to be followed by his pcp. . resp failure: patient cxr initially showed with diffuse pulmonary edema. his failure was attributed to both septic and cardiac failure and he was found to have vent associated pneumonian afterwards. patient was oxygenating well after aggressive diuresis. his oxygenation status also improved. patient however still required high peeps. patient has a compromised pulmonary status at baseline and is followed by a pulmonologist as an outpatient and was electively being evaluated for a tracheaostomy due to sleep apnea, pulmonary hypertension and obesity hypoventilation. patient previously did not tolerated cpap at night. pulmonary service was consulted after patient failed spontaneous breathing trials and after 2 weeks on ventilator, a tracheostomy was recommended. patient subsequently underwent peg and tracheostomy placement on by minimally invasive surgery. patient tolerating the procedure well without complications. his sedation with fentanyl and versed was subsequently weaned and he was further diuresed. patient was doing well on trach mask during the day requring 40-50% fio2. he was rested at night with cpap of . had an acute desaturation requiring pulmonary toilet, suctioning and replacement on a/c for the rest of the evening. he was placed on cpap and sunday was again on trach collar doing well. thought patient had aspirated but his white count remained stable and cxr was w/o infiltrates. patient is to follow up with his pulmonologist and to undergo aggressive pulmonary rehab. the ultimate goal of tracheostomy reversal may be difficult to achieve. . nstemi: patient was found to have elevated cardiac enzymes during his hospital course. peak ck was 1766 and peak troponin t was 2.95. his ekg initially did not show any ischemic changes and remained with af and incomplete rbbb. he was taken to cardiac cath upon transfer on and was found to have diffuse 3 vessel disease. ct surgery was consulted and recommended further stabilization medically of this diabetic, septic, hypotensive patient with ? of demand infarct and acute renal failure. after 2 weeks patient was also re-evaluated but with heparin antibody and intermittent pressor requirement he was deemed to be high risk. patient was then taken to the cath lab for lad intervention. he was continued on aspirin, statin, plavix, heparin and then argatroban drip and beta blocker and ace were restarted. patient was taken bath to cath lab on where his lad was stented with 2 , des in rca and baloon angioplasty in lcx. the procedure was without complications. patient remained chest pain free. . acute renal failure: patient's baseline was unknown. he was admitted with cr of 3.0 but with good urine output. his urine lytes revealed a pre-renal state. they slowly improved to 1.5 and were deeemed likely to be due to hypoperfusion. there may have also been an element of contrast nephropathy despite receing mycomyst and prehydration with bicarbonate. renal us () was also normal. patient remained with good urine output. he tolerated diuresis well with lasix prn and lasix gtt. his cr returned to his baseline of 1.1. . pump: echo : 45% ef, anterior hypokinesis, no valvular abnormalities. patient tolerated diuresis well. patient was continued on bb and acei as they were titrated up. . dm-2: cont iss, patient may be able to return to oral hypoglycemic upon his discharge home. . heparin induced thrombocytopenia: after several days on iv heparin, patient was found to thrombocytopenia (88 from 190k upon admission after 5 days). hit antibody screen was done, and was found to be positive. heparin products were stopped and argatroban was started. patient will need anticoagulation for at least 30 days after last heparin dose to reduce risk of thrombosis or until patient will be restarted on coumadin for his af. patient was subsequently therapuetic on coumadin with inr of and argatroban gtt was turned off. his platelet returned to baseline. . fen: thin liquid, regular solid, cardiac diet . ppx: coumadin, colace, senna, ppi . communication: mother , girlfriend is also involved. . code: full medications on admission: meds at home: coumadin (7.5mg 2x/wk; 5mg 5x/wk) actos lasix 40mg (but only taking on weekends) toprol xl 25 mg lipitor 10mg amaryl 4mg discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. atenolol 50 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<100, hr<50. 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. warfarin 2 mg tablet sig: 1.5 tablets po hs (at bedtime). 6. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. 7. dolasetron 12.5 mg/0.625 ml solution sig: one (1) intravenous q8h (every 8 hours) as needed for nausea. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 11. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 12. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4-6h (every 4 to 6 hours) as needed. 13. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed. 14. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day). 15. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 16. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 17. insulin regular human 300 unit/3 ml insulin pen sig: units subcutaneous every 4-6 hours: per sliding scale. 18. lisinopril 10 mg tablet sig: 1.5 tablets po daily (daily). discharge disposition: extended care facility: - discharge diagnosis: 1. septic shock 2. cardiogenic shock 3. nstemi - s/p des to lad, rca and baloon angioplasty in lcx 4. respiratory failure 5. mrsa bacteremia discharge condition: stable. afebrile. tolerating po. patient sating well on trach mask during the day with cpap 10/5 @ night. discharge instructions: please take all your medications as instructed. it is important that you take your plavix and aspirin until told otherwise by your cardiologist. you should also follow up with your cardiologist and your pulmonologist. if you experience any chest pain, shortness of breath, nausea/vomiting or sweating please seek immediate medical attention. followup instructions: please follow up with your pcp, . , y please follow up with your cardiologist dr. , your cardiologist @ (. please follow up with your pulmonologist dr. @ ( in weeks. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more combined right and left heart cardiac catheterization coronary arteriography using two catheters coronary arteriography using two catheters left heart cardiac catheterization diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy implant of pulsation balloon insertion of drug-eluting coronary artery stent(s) injection or infusion of oxazolidinone class of antibiotics excision of lingual thyroid percutaneous transluminal coronary angioplasty [ptca] insertion of three vascular stents destruction of cranial and peripheral nerves procedure on three vessels diagnoses: pneumonia, organism unspecified obstructive sleep apnea (adult)(pediatric) subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia atrial fibrillation infection with microorganisms resistant to penicillins cardiogenic shock septic shock intestinal infection due to clostridium difficile morbid obesity long-term (current) use of anticoagulants methicillin susceptible pneumonia due to staphylococcus aureus anticoagulants causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to