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: influenza virus vaccine / shellfish derived / egg / adhesive bandage / heparinoids attending: chief complaint: fever major surgical or invasive procedure: sternal wound debridement history of present illness: 67 yo f with h/o dm, htn, hit, pe, mitral valve replacement & cad s/p cabg c/b chronic sternal wound infection with multi-drug resistant pseudomonas and esbl e.coli, who presented from rehab with fevers for evaluation of sternal wound. on ros, also c/o chronic sternal and right-sided chest wall pain reproducible to palpation. endorses sob and cough productive of white phlegm for the past 2 weeks. . in the ed, initial vs were: 98 110 133/46 33 100% 4l. she was tachypneic with sob and cough, rectal temp 103. cxr showed left base atelectasis. cta chest done and unchanged with no pe. she was clinically felt to have pneumonia and treated with vancomycin, ceftriaxone, and levofloxacin. cpap attempted temporarily for tachypnea without substantial effect; her tachypnea was felt to be more related to anxiety, as her rr improved while asleep. ekg was unchanged. abg attempt unsuccessful. received aspirin as well as albuterol/ipratropium nebs and methylprednisolone for possible copd. past medical history: - diabetes - hypertension - cad s/p prior rca stenting c/b isr x 2, cypher stenting in for nstemi, s/p cabg x 2 with lima-lad, svg-pda - mvr : 25 mm mosaic porcine valve - non sustained polymorphic vt s/p icd placement - chronic sternal wound infection since with multiple highly resistant organisms - vte on warfarin - hit (heparin-induced thrombocytopenia) - mengingioma, formerly on chronic steroids - osteopenia/porosis - s/p tah-bso - h/o c diff - depression - anxiety - hypercholesterolemia - h/o large post cath rp hematoma, - gastroesophageal reflux disease - history of pulmonary nodules, followed by serial imaging - history of h. pylori - history of gi bleed in the setting of anticoagulation social history: currently at . she has a brother and sister who are her supports and she plans to live with her brother when discharged from rehab. past smoker (30 pk yr), no etoh or drugs. currently in a wheelchair at baseline. family history: father died at age 50 of an mi and "enlarged heart." brother with drug abuse. mother had depression and panic attacks, dm. physical exam: discharge exam: pertinent results: discharge labs: imaging: cxr: minimal left basilar atelectasis. . : cta chest w&w/o c: 1. no evidence of pulmonary embolism. no evidence of acute cardiothoracic process. 2. no change of post surgical changes at the sternum. no evidence of fluid collection. no change of the sternal bed compared to . 3. mild prominence of the left adrenal gland, more conspicuous than on prior exam. . ruq u/s: mildly thick-walled gallbladder, with mobile gallstone, and without other signs of cholecystitis uch as distension, pericholecystic fluid or tenderness. acute cholecystitis is not excluded. if there is continued clinical concern, a hida scan could be obtained for further evaluation. . echocardiogram (tee) : mild spontaneous echo contrast is seen in the body of the left atrium. no mass/thrombus is seen in the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with severe inferior, inferoseptal, and lateral hypokinesis. overall left ventricular systolic function is mildly depressed (lvef= 40 %). 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. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). trace aortic regurgitation is seen. the motion of the mitral valve prosthetic leaflets appears normal. they may be mildly thickened. no mass or vegetation is seen on the mitral valve. there is a minimally increased gradient consistent with trivial mitral stenosis. trivial , central valvular mitral regurgitation is seen. dr. was notified in person of the results in the operating room at the time of the procedure. . cta chest:1. there is no evidence of a central 1st-3rd order pulmonary embolism. the pulmonary artery is normal in diameter (25 mm). embolism distal to this level cannot be excluded due to suboptimal image quality. 2. small bilateral pleural effusions, slightly enlarged since . mild stable left upper lobe atelectasis. 3. global cardiac enlargement, stable since . 4. sternal wound and probable associated anterior chest wall fluid collection/cellulitis consistent with the given history of recurrent sternal wound infection and recent debridement. . ct head: unchanged size and appearance of right frontal extra-axial mass, likely a meningioma, with unchanged surrounding edema and mass effect. no evidence of new intracranial abnormalities. . cxr: the pacemaker defibrillator leads are in unchanged position. cardiomediastinal silhouette is unchanged. lungs are essentially clear. note is made that the pacemaker is obscuring parts of the left lung base. no appreciable pleural effusion is demonstrated. no appreciable pneumothorax is seen. . b/l le u/s: no evidence of deep vein thrombosis in either leg. . cxr: no evidence of fluid overload. no acute cardiopulmonary abnormality. . microbiology: mrsa screen mrsa screen- negative culture culture, negative urine urine culture- negative culture culture, routine- negative culture culture, routine- negative culture culture, routine- negative culture culture, routine- negative culture culture, routine- negative swab gram stain-final; wound culture-final {pseudomonas aeruginosa}; anaerobic culture-final inpatient urine urine culture- negative culture culture, routine-final {klebsiella pneumoniae}; aerobic bottle gram stain-final; anaerobic bottle gram stain culture culture, routine-final {klebsiella pneumoniae}; aerobic bottle gram stain-final; anaerobic bottle gram stain . culture data (organism and susceptibilities): 1:25 pm culture klebsiella pneumoniae. final sensitivities. sensitive to tigecycline at mic 1.5 mcg/ml colistin susceptibility testing requested and pending ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- =>64 r ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- =>128 r tobramycin------------ 8 i trimethoprim/sulfa---- =>16 r 9:55 am swab source: sternal wound. pseudomonas aeruginosa. sparse growth. colistin susceptibility testing requested and pending amikacin-------------- 16 s cefepime-------------- 16 i ceftazidime----------- 16 i ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem------------- =>16 r piperacillin/tazo----- =>128 r tobramycin------------ =>16 r . pathology: surgical specimen: the acute inflammation focally involves the cartilage. most of the cartilage appears viable with focal necrosis. brief hospital course: 67 year-old w with hypertension, diabetes mellitus ii, history of heparin-induced thrombocytopenia, pulmonary embolism, porcine mitral valve replacement and coronary artery disease status-post cabg () complicated by chronic sternal wound infection with multi-drug resistant pseudomonas and extended-spectrum beta-lactamase e coli who presented from rehab with fever and was found to have esbl klebsiella bacteremia, and mdr pseudomonas in her sternal wound. she was placed on iv colisitin. on she went for surgical debridement of her chronic wound by plastic surgery. after which, she had a wound vac in place. . the patient's extended hospital course was complicated by an episode of tachycardia (appeared to be multifocal atrial tachycardia), hypotension, and altered mental status for which she was transferred to the icu. the inciting event is unclear. ct head was negative for acute change, ct chest angio was negative for pe. she had evidence of an nstemi, likely secondary to increased demand in the setting of tachycardia. an echocardiogram revealed no changes. daptomycin was added for increased antibiotic coverage, but then removed after the patient improved relatively quickly with little intervention except for hydration, then lasix, and metoprolol for heart rate control. she did have a drop in hematocrit for which she received 1u prbc with an appropriate response. stools were guaiac negative, hemolysis and dic labs were also negative. she was transferred back to the floor and remained stable for the rest of her admission. . # bacteremia: the patient's initial cultures (4/4 bottles) grew esbl klebsiella. her wound culture grew mdr pseudomonas. her urine culture was negative. given the resistance profile she was started on iv , infectious disease recommendations. plastic surgery was concerned for possible gallbladder pathology and requested a ruq ultrasound, which revealed a midly thick gallbladder with mobile gallstone and no other evidence of acute cholecystitis. a chest ct showed no change in her sternal wound, no evidence of fluid collection. given that the wound was the likely source of her bacteremia, she underwent debridement on by plastic surgery with subsequent wound vac placement. she was continued on iv colisitin for two weeks following debridement (last day ). she remained afebrile, and without a leukocytosis. her surveillance cultures were all negative. plastic surgery performed regular wound vac changes. her wound appears to be healing well. her pain was controlled with 0.5 of iv morphine. she will need continued wound vac changes twice weekly. she will also need to follow up with dr. of plastic surgery, and with the infectious disease specialists, as specified in his dischrage worksheet. . # anticoagulation: given her history of venous thromboembolisms while on coumadin, mitral valve replacement, and history of heparin-induced thrombocytopenia, the patient was placed on an argatroban drip prior to and after her surgical procedure. this was discontinued in the micu. she was then re-started on coumadin after transfer to the floor. she was kept on pneumboots until her inr was consistently theraputic (goal ). on discharge she was on coumadin 2 mg daily, given at 4pm. she will need continued work to monitor her inr and re-dose the coumadin as appropriate to achieve inr goal of . . # acute kidney injury: the patient has had a slowly increasing creatinine (1.1 on day of discharge, 0.5-0.6 baseline) secondary to poor po intake and low volume status. we have held her lasix (normal dose furosemide 20 mg po daily) and lisinopril (normal dose 5 mg po daily). she will need monitoring of her kidney function by repeat creatinine measurements, and likely future re-initiation of her anti-hypertensives once her volume status corrects and kidney injury resolves. also, the patient has needed frequent repletion of her potassium and magnesium during her hospitalization, likely due to poor nutritional status and being on diuretics. now that her furosemide has been held, we anticipate these repletions will be less frequent. she will need monitoring of her electrolytes, and supplementation as needed, upon arrival to the skilled nursing facility. . # anemia: the patient has a chronic, normocytic anemia that slowly trended downwards during her admission. her stools were guaiac negative, and she had no evidence of hemolysis or dic. she likely had appreciable loss from her surgical site, as the wound vac output was sanguinous. her hematocrit never fell below 21%, but given her cardiac history, and physiologic signs such as tachycardia, as well as endorsed dyspnea, she received one unit of packed red cells on two separate occasions, and responded appropriately. . # malnutrition: the patient was assessed by nutrition who recommended tube feeds. the patient was hoff tube placement for supplementation on three separate occasions and refused. this should be addressed in the future. . # tachypnea: the patient's respiratory rate has been elevated since admission, and does not correlate with the sensation of dyspnea. this appears to be chronic in nature, perhaps secondary to her severe kyphosis and an element of anxiety. there was no evidence of pulmonary embolism seen on two different chest cta. her cxrs were negative for pneumonia or signs of fluid overload. her oxygen saturation remained within normal limits on room air. occasionally she complained of dyspnea, and wheezes were heard on pulmonary exam. she responded well to ipratropium nebulizers. . # dmii: the patient has a history of diabetes mellitus. she was provided regular accuchecks and placed on an insulin sliding scale. she rarely needed insulin during this admission. we are not discharging her on any medications for management of diabetes; when she presented to the hospital from rehab she was not on any agents either. . # htn: the patient's pressure ranged from systolics high 90s to 110s and diastolics from 50s to 60s. she was kept on metoprolol 25 tid. lasix and lisinopril have been recently held (as explained above). . # cad: nstemi in micu as described above. she is being discharged on daily aspirin, statin, and beta-blocker. her lisinopril is being held until future re-assessment. . # depression/anxiety: continued lorazepam and aripiprazole. there are prior records that indicate she was once on citalopram. she can be re-assessed in the future, and this re-initiated if necessary. . # gerd: continued on omeprazole. # prophylaxis: the patient did not receive heparin products during this admission. she received a temporary argatroban drip, then re-initated on coumadin and wore pneumatic boots. # code status: full code . # considerations: this patient has baseline poor functional status. upon presentation she was wheelchair bound, unable to walk unassisted, unable to climb a flight of stairs. no baseline home o2 requirement medications on admission: 1. lisinopril 20 mg daily 2. metoprolol succinate 150 mg daily 3. furosemide 20 mg daily 4. lorazepam 0.5 mg q6h as needed for anxiety. 5. lorazepam 1 mg hs 6. colace 200 mg twice a day 7. simvastatin 40 mg daily 8. hydrocodone-acetaminophen 5-500 mg 1-2 tabs q6h as needed for pain. 9. hydroxyzine 25 mg as needed for itchiness. 10. depakote 250 mg tablet, delayed release twice a day 11. warfarin 3.5 mg once a day 12. vitamin d-3 400 unit daily 13. citalopram 40 mg daily 14. calcium carbonate 1000 mg daily 15. albuterol sulfate 2.5 mg /3 ml (0.083 %) neb q6h prn sob/wheezing 16. aspirin 325 mg daily 17. bisacodyl 5 mg prn constipation 18. omeprazole 20 mg daily 19. aripiprazole 2.5 mg daily 20. mag oxide 400mg 21. kcl 20 meq daily 22. apap 650mg q4h prn pain/temp 23. nystatin cream prn rash 24. nystatin powder to l axilla, under bilat breasts discharge disposition: extended care facility: care and rehabilitation center discharge diagnosis: primary diagnosis: - bacteremia - chronic sternal wound infection . secondary diagnosis: - coronary artery disease - chronic systolic heart failure - hypertension - diabetes mellitus (non-insulin dependent) - hyperlipidemia - gastroesophageal refulx disease - meningioma - depression - anxiety - malnutrition discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mrs. , . you were admitted to the hospital for fevers and found to have an infection in your and your sternal wound. you received antibiotics and had a surgery to remove some of the infected tissue from your sternal wound. you did well. your hospital course was complicated by a short transfer to the icu (intensive care unit), after which you improved. you are being discharged to a skilled nursing facility for continued care. . we have made some changes to your medications, which are listed in detail in your instruction sheet. please continue to take them as instructed. importantly, we are holding some of your pressure medications (furosemide 20 daily and lisinopril 5 daily). you will need to be re-evaluated by a doctor to determine if you need these re-started in the near future. . additionally, you will need close monitoring of your inr and coumadin dosing. you will also need to have wound vac changes twice weekly. . please keep your follow up appointments with the infectious disease and plastic surgery doctors. followup instructions: name: , location: plastic surgery, pc address: , , , phone: appointment: thursday 1:45pm . department: infectious disease when: wednesday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage procedure: arterial catheterization local excision of lesion or tissue of bone, other bones central venous catheter placement with guidance sequestrectomy, scapula, clavicle, and thorax [ribs and sternum] diagnoses: pneumonia, organism unspecified other iatrogenic hypotension subendocardial infarction, initial episode of care esophageal reflux other postoperative infection unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified protein-calorie malnutrition severe sepsis obstructive chronic bronchitis with (acute) exacerbation acute on chronic diastolic heart failure coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status unspecified osteomyelitis, other specified sites percutaneous transluminal coronary angioplasty status hypopotassemia dysthymic disorder other and unspecified hyperlipidemia other specified cardiac dysrhythmias cardiogenic shock osteoporosis, unspecified septic shock benign neoplasm of cerebral meninges long-term (current) use of anticoagulants automatic implantable cardiac defibrillator in situ other septicemia due to gram-negative organisms other diseases of lung, not elsewhere classified personal history of venous thrombosis and embolism surgical or other procedure not carried out because of patient's decision surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation altered mental status precipitous drop in hematocrit disorders of magnesium metabolism pseudomonas infection in conditions classified elsewhere and of unspecified site heparin-induced thrombocytopenia (hit) personal history of pathologic fracture predominant disturbance of emotions acquired deformity of pelvis 

Answer: The patient is high likely exposed to