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: left-sided shaking major surgical or invasive procedure: intubation history of present illness: 69 yo male with h/o aaa s/p repair, mesenteric ischemia s/p resection, cad, htn, pvd, cri who presented to from rehab with seizures. he was intubated, admitted to icu, and controlled on vpa, dilantin, phenobarbitol and keppra. he had a prolonged intubation, and had a tracheostomy performed on . he has been on nuerology service for propofol induce coma for focal motor status epilepticus presumably due to right hemisphere cortical infarcts. his admission has been highlighted by intubation, tracheostomy, and successful placement of pmv, pneumonia, uti, gpc bacteremia. . he started becoming hyponatremic around . his sodium was normal on admission, and was stable until this time. since then, it has slowly drifted down to 124. his other electrolytes, including renal function, has been stable during this time. he started with tube feeds on . his initial free water flushes were 30ml q 6 hours. on his free water flushes were increased to 100ml q 4 hours. on his free water flushes were decreased to 100mg q 6 hours. today, , his free water flushes were decreased to 50mg q 6 hours. serum osm were 276 on . urine sodium on was 71. urine osm on were 292. subsequent urine osm 400s . . he has also been anemic during this admission. he was admitted with a hct of 45% last admission, and it has been mostly in the mid 20's to mid 30's since that time. it has gotten as low as 19.9% on . he has been transfused 2 units , two units on , and 1 unit on . per report, he has been having diarrhea, and is guaiac positive, though no clear melena. he has never had a scope in our system. he has not had any iron studies during this admission. . he has had several infectious issues, he was treated with meropenem from to for resistant e. coli uti and pneumonia. he has had several negative c.diff cultures, and was treated with flagyl empirically for several days. this has been stopped. on he was started on cipro for an e.coli uti (found to be cipro resistent), and on he was started on vanco for coag. negative staph in blood culture bottles. . review of systems: currently, he only c/o headache, frustration at not being able to get out of bed, unable to speak w/o pmv. past medical history: hyperlipidemia htn embolic stroke in 10/97 with 7 since then (most recent ) cad/mi x 3 aaa - infrarenal 4.8cm s/p repair pvd cri chf (depressed ef) afib s/p ablation sdh fall in right fem in situ (93) s/p left fem in situ (93) vein angioplasty of left femoral artery 01 ercp stent hearing impairment ischemic bowel s/p sb resection etoh abuse social history: heavy drinker, 1ppd tobacco, used to work as a lawyer (real estate property) and retired in his 50s family history: nc physical exam: admission physical exam: t afebrile; bp 110/67 . general: intubated, sedated heent: ncat, moist mucous membranes neck: supple, no carotid bruit pulmonary: cta b/l cardiac: regular rate and rhythm, with no m/r/g carotids: no blood flow murmur abdomen: soft, nontender, non distended, normal bowel sounds extremities: no c/c/e. . neurological exam: mental status: intubated sedated, not responding to verbal stimuli. . cranial nerves: perrl, 4-->2mm with light. blinks to threat. face symmetric. + vor. . motor/ does not withdraw to painful stimuli. . reflexes: bic t br pa ac right 2 2 2 2 2 left 2 2 2 2 2 toes upngoing bilaterally. . physical exam on transfer to medicine service: . vs- 98.3 82 110/46 15 100% (40% tm) fs 140 gen- elderly, frail appearing male lying in bed with trach collar on, pmv not in place, nad heent- mm dry, anicteric, no oral lesions, eomi, perrl neck- jvp flat, tracheostomy site c/d/i, supple cv- rrr, no m/r/g appreciated, though loud sounds from trach mask chest- diffuse expiratory wheeze anteriorly, equal abd- soft, nt, no hsm, gtube in place without surrounding erythema, pos bs ext- no edema. pneumoboots and multipodus boots in place. neuro- aao x 2, eomi, decreased motor strength throughout skin- site of former r. subclavian line cdi (line pulled prior to exam), g-tube site cdi. dry skin. pertinent results: admission labs: 04:15pm urine color-yellow appear-clear sp -1.035 04:15pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:15pm urine rbc-* wbc- bacteria-few yeast-none epi-0-2 04:15pm urine hyaline-0-2 04:10am glucose-100 urea n-8 creat-0.7 sodium-138 potassium-3.9 chloride-108 total co2-22 anion gap-12 04:10am alt(sgpt)-10 ast(sgot)-21 alk phos-82 04:10am %hba1c-5.9 04:10am triglycer-170* hdl chol-28 ldl(calc)-8 cholest-70 04:10am phenytoin-6.5* 04:10am wbc-16.9* rbc-2.97* hgb-8.7* hct-27.4* mcv-92 mch-29.4 mchc-31.9 rdw-15.1 plt count-591* 04:10am pt-12.9 ptt-28.8 inr(pt)-1.1 02:07am glucose-86 na+-137 k+-5.5* cl--109 tco2-22 02:06am urea n-9 creat-0.8 02:06am alt(sgpt)-13 ast(sgot)-40 ck(cpk)-131 alk phos-86 tot bili-0.5 lipase-62* 02:06am ck-mb-3 ctropnt-0.02* 02:06am albumin-2.4* 01:50am fibrinoge-307 . cta head and neck and ct perfusion : 1. no evidence of intracranial hemorrhage or edema. no asymmetry identified on the ct perfusion study. 2. atherosclerotic calcifications involving the origins of the great vessels from the aortic arch. atherosclerotic calcifications at the origins of the vertebral arteries bilaterally and stenosis involving these origins cannot be excluded. 3. no hemodynamically significant stenosis involving the carotid arteries throughout their course bilaterally. 4. unremarkable cta of the circle of . . mri/mra head : 1. scattered, tiny foci of diffusion-weighted imaging abnormality involving the cerebral hemispheres and the left thalamus which could represent subacute infarction. 2. signal dropout involving the supraclinoid right internal carotid artery which is likely secondary to atherosclerotic calcified plaque causing moderate stenosis as seen on the previous ct angiogram. . eeg : this is an abnormal eeg in the waking and drowsy states due to the runs of rhythmic slowing in the right central region and posterior quadrant with superimposed sharp waves and persistent intermixed theta and delta slowing. these abnormalities suggest brief electrographic seizures in the right posterior quadrant with evidence of underlying subcortical dysfunction . eeg : this telemetry captured six pushbutton activations. two of those and several of the automated seizure detection segments showed clinical seizures. at baseline, there was high voltage right hemisphere and especially right frontal sharp wave discharges that were not particularly rhythmic but recurred at about 1.5-2 hz throughout the recording. when these became more rhythmic or when there was still faster activity with spread of slowing to the left, there appeared to be clinical seizures. many of these clinical seizures were primarily jerking of the left body, but with bilateral eeg changes there was jerking activity on the right, as well. the tracing suggests frequent clinical seizures along with a persistent and active epileptogenic lesion in the right hemisphere, likely anteriorly . ct chest, abd, pelvis : 1. postoperative appearance to the abdomen after small bowel resection. small inflammatory change with extraluminal gas adjacent to the distal small bowel, which is likely post-surgical change. however, because of the recent ischemic event and persistent small bowel wall thickening, close clinical follow up is recommended. 2. moderate amount of ascites, small to moderate bilateral pleural effusions with associated atelectasis. small pericardial effusion. 3. compression deformities of t11 and l1 vertebral bodies, stable. 4. patent aorto-biiliac graft. . ct abd/pelvis : 1. postop changes within the abdomen up to small bowel resection. interval resolution of the extraluminal gas seen adjacent to the distal small bowel with unchanged soft tissue density with few foci of increased density within it, which may represent dystrophic calcification. the surrounding fat stranding is likely represents scarring from postoperative change, attention to this region on followup examinations is recommended. 2. interval resolution of the small bowel wall thickening seen on prior exam. 3. patent sma stent. 4. interval resolution of bilateral pleural effusions and bibasilar atelectasis with residual sub segmental atelectasis at the right lung base. . tte : the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. lv systolic function appears depressed (cannot quantitate); the anterior septum and anterior free appear hypokinetic. right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is no pericardial effusion. suboptimal image quality - patient unable to cooperate. no atrial septal defect seen on bubble study (2 rest injections). . eeg : this 24-hour video eeg telemetry captured no electrographic seizures or interictal epileptiform discharges. the background was slow and disorganized throughout the recording representative of a mild to moderate encephalopathy. compared to the prior day's recording, the degree of encephalopathy appeared slightly less . cxr : tracheostomy tube and catheter are in standard position. cardiac and mediastinal contours are within normal limits and unchanged. lungs remain grossly clear, and no pleural effusions or pneumothoraces are identified on this portable projection. . left hip plain films: comparison is made to a ct from . there are marked arterial calcifications, as seen previously. there are bilateral degenerative changes at the hip joints with osteophytes but no fracture, dislocation, or bony destruction. impression: no evidence of fracture. brief hospital course: the patient presented as a code stroke; tpa was not given due to his recent surgery. he was admitted to the neuro-icu intubated and loaded on dilantin. he was soon extubated without subsequent respiratory difficulty and continued to be monitored for seizure activity. from , he had continuous eeg monitoring, which was positive for at least 6 seizures, some of which spread contralaterally, and for right-sided discharges and sharp activity. he was started on keppra 500mg on , which was increased to 750mg on , at which point he was transferred to the neurology floor. mri showed scattered, tiny foci of diffusion-weighted imaging abnormality involving the cerebral hemispheres and the left thalamus which could represent small subacute infarction, but no large territorial infarcts were seen. lp is negative for meningitis. his antihypertensives were initially held, then restarted after stroke was ruled out. his lipid panel was significant for ldl of 8 and lipitor was discontinued (due to malabsorption? poor nutrition?). . pt. was monitored on the floor from - . eeg continued to show frequent r sided discharges and he continued to have continuous left arm and leg twitching c/w epc. keppra was titrated up to 1500 and dilantin 300 qd was continued. he was also started on depakote which was titrated up to 500 tid, phenobarbital which was titrated up to 100 , and ativan 0.5 q8. tms was attempted on and and was unsucessful at stopping the seizures. given that all of these intervention, pt. was transferred to the icu for 48hr burst suppression with propofol on . his keppra was titrated further to , depakote to 900 mg q3h, and dilantin to 55 mg iv q6h. propofol was discontinued after 2 days, and discharges on eeg and clinical seizures resolved, although the patient continued to be deeply encephalopathic. repeat head ct was negative and encephalopathy has improved slowly with discontinuation of phenobarbital. his icu course was complicated by esbl e coli pna/uti and the patient was treated with a 10-day course of meropenem. . extensive workup for causes of epilepsia partialis continua was negative (apart from a weakly positive 14-3-3, which can be falsely elevated by acute infarction). the acute infarct seen on mri was thought to be the cause. . on , the patient was transferred to the floor for continued treatment. his encephalopathy had lightened with reduction of his anticonvulsant levels and cessation of phenobarbital. his aeds were weaned over the next week, and eventually depakote was weaned off, keppra was weaned down to 1000 mg (level high in 70s on ), ativan was weaned off, and phenobarbital was weaned. . other issues include an elevated psa and the patient should be seen by urology as an outpatient. . he was transferred to the medicine service on for continued management of his multiple medical problems and course is outlined as below: . # uti: esbl e. coli resistent to multiple abx; sensitive to zosyn, meropenem, imipenem, nitrofurantoin. given his weakness and inability to use urinal on his own at this point and concern for skin breakdown, foley was changed, but maintained in place. at rehab, he should have his foley catheter discontinued as soon as possible for voiding trial as this is the second e. coli uti for which he is being treated during this hospitalization. he will need to complete a 14 day course of zosyn last day . . # ? bacteremia: blood cultures drawn on revealed sets positive for coagulase negative staph. he was started on vancomycin by the neurology team at that time. surveillance cultures were not drawn after until and subsequent daily surveillance cultures have shown ngtd. his right sc line was d/c'd on as a possible source. given cultures positive for coagulase negative staph (normal skin flora) it is not entirely clear whether this represents contaminant vs. true bacteremia. additionally, he developed an absolute eosinophilia while on vancomycin, thus it was felt reasonable to hold the vancomycin and observe clinically and with daily surveillance blood cultures. as his vancomycin was originally supratherapeutic, it took several days to trend downward below therapeutic range, but consistently, surveillance cultures since the original positive have shown no growth thus far. final cultures should be followed up and his clinical status should be monitored closely in this setting. . # leukocytosis: with significant eosinophilia as discussed below. given e. coli uti and e. coli in sputum (likely representing tracheitis/tracheobronchitis as no clear infiltrate on cxr), wbc count elevation is likely in this setting. although he does have persistent diarrhea, c. diff has been negative on multiple checks. a c. diff toxin b was sent and is pending and should be followed up on. he is being treated with a 14 day course of zosyn for the above infections. . # eosinophilia: absolute eosinophilia (mild noted prior to vancomycin, but significant increase after vanco initiation) with vancomycin initiation although differentials not followed consistently upon initiation. there were no other clear medication causes as absolute eosinophil count had previously been normal when new antiepileptic medications were started. vancomycin was supratherapeutic upon transfer to medicine service and given not entirely clear whether blood cultures represent true infection, vancomycin was held with daily surveillance blood cultures drawn. his renal function remained stable so as not to suggest ain and he was without rashes. his cbc/diff should be monitored on discharge to assess for resolution of eosinophilia off vancomycin (absolute eosinophilia maxed at 3700 and is 1100 on day of discharge). . # respiratory secretions: significant amount of secretions requiring suctioning has been ongoing since trach placement, but have improved significantly (no longer requiring frequent suctioning) following initiation of zosyn. he does, however, have a strong cough and has been able to clear much of these secretions on his own. cxrs did not reveal focal infiltrates to suggest pulmonary infection as cause of increased secretions. thus, likely tracheitis/tracheobronchitis causing the substantial secretions. his most recent sputum culture showed oral flora as well as esbl e. coli (sparse growth). as above, he will be treated with a 14 day course to which his infection is susceptible (complete course ). he has an appointment scheduled with pulmonary medicine at to address his question of trach reversal. he will be discharged on 40% o2 via trach mask with o2 saturation 98-100%. . # anemia/gi bleed: baseline hematocrit prior to this extended hospitalization is unknown, but hct reached a low of 20 during this admission in the setting of guaiac + brown stool and he required prbc transfusions during his stay (last on ). post transfusion, his hematocrit remained stable in the high 20s to low 30s (29.4 on day of discharge). his anemia is normocytic with elevated rdw. iron and tibc low, ferritin normal so certainly element of acd with iron deficiency. gi evaluated him here and thought gi bleed as well as anemia was multifactorial. he likely has ongoing ischemia given significant h/o ischemic disease and has malabsorption given recent small bowel resection to gut ischemia. also, it was thought that he may have some small amount of oozing from peg site as this was placed post bowel resection. given his multiple other medical matters and stable hematocrit, it was decided not to pursue endoscopy/colonoscopy while inpatient, but this should be pursued upon discharge. he has a follow up appointment with gastroenterology at to further discuss his diarrhea and gi bleed as will likely need outpatient scope. . # diarrhea: c. diff and stool studies were negative on repeat checks. c. diff toxin b was sent and is pending. he has had ongoing diarrhea since his small bowel resection for ischemic gut, but it has been worsened during this stay. as above, her gi evaluated him and thought that much of his diarrhea was secondary to "short gut" and thus malabsorption post resection. additionally, he may have continued element of ongoing ischemia contributing. per gi recommendations, he was started on bile acid sequestrant cholestyramine. tube feeds were originally held as they were thought to be exacerbating his diarrhea, with some improvement while off. glutamine was started per nutrition's recommendation in the setting of short gut syndrome. they were reinitiated with continued improvement in his diarrhea (please seen fen section below). as above, c. diff toxin b should be followed up on and if negative, can use loperamide and tincture of opium as written below. . # hyponatremia: originally evaluated by medicine consult while on the neurology service for worsening hyponatremia. he had been getting increased free water flushes since in an attempt to volume resuscitate him, which likely contributed to his hyponatremia. of note, he was also on lasix during the entire time, which with free water administration contributed. his renal response to the hyponatremia suggested impaired ability to dilute the urine, with elevated urosm. this could suggest siadh, either from recent surgery/ventilation, less likely from cns process as his seizures have been well controlled. free water flushes were changed to normal saline and iv medications were mixed with ns instead of sterile water. he was taken off standing lasix with close monitoring of his fluid status and prn dosing; this should be monitored upon discharge as well. with the above changes, his sodium normalized and has remained stable. . # weakness: diffuse and unable to assess focal deficits. given prolonged micu course and illness, likely representative of deconditioning and even icu neuropathy/myopathy although he did not have formal studies including emg. he does, however, have h/o multiple cvas, but given no clear focal deficits, seems less likely to cva although possible. he did not have further mri imaging while here as his weakness, especially in upper extremities, has been improving. . # seizures: please see discussion as above per neurology. he has been maintained on keppra alone since transfer out of the icu without seizure activity while on the floor. his keppra was transitioned from iv dosing to delivery via his peg. he has follow up with neurology scheduled. . # left hip pain/low back pain: onset of left hip pain was after having been moved from bed to chair. plain films did not reveal dislocation nor fracture. his low back pain is chronic in nature (preceded well before aaa diagnosis and has lasted beyond repair) and has increased with immobility and with transfers from bed to chair. pain has been well controlled with dilaudid. he should be transitioned off iv pain meds as possible while at rehab. . # fen: tube feeds were held briefly as they were thought to be playing a role in his diarrhea. they were then started at half strength and worked back up to full strength. he is still, however, not meeting protein goal at full strenth vivonex at 80cc/hour. he is receiving glutamine per nutrition recs to aid in absorption in setting of short gut and cholestyramine per gi recommendations for his diarrhea. speech and swallow should evaluate the patient with trach in place at rehab to assess for ability to supplement tube feeds with po intake. . # proph: venodynes and sc heparin. . # access: right subclavian line was removed on . he has a right picc line placed on . foley was last changed on . . # communication: son is health care proxy . . # code: full (discussed w/ hcp) medications on admission: meds obtained from discharge summary: 1. albuterol 90 mcg/actuation aerosol : 1-2 puffs inhalation q6h (every 6 hours) as needed. 2. aspirin 325 mg tablet : one (1) tablet po daily (daily). 3. ipratropium bromide 17 mcg/actuation aerosol : two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. 4. oxycodone-acetaminophen 5-325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed: do not exceed 4 grams of acetaminophen per day when also giving percocet. 6. metoprolol tartrate 50 mg tablet : one (1) tablet po tid (3 times a day). 7. clonidine 0.2 mg/24 hr patch weekly : one (1) patch weekly transdermal qthur (every thursday). 8. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 9. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 10. psyllium 1.7 g wafer : wafers po daily (daily). 11. heparin (porcine) 5,000 unit/ml solution : one (1) injection twice a day. 12. lipitor 80 mg tablet : one (1) tablet po once a day. discharge medications: 1. piperacillin-tazobactam 4.5 g recon soln : 4.5 grams intravenous q8h (every 8 hours): note: course to be completed on . 2. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) inhalation q6h (every 6 hours) as needed. 3. albuterol 90 mcg/actuation aerosol : three (3) puff inhalation q4h (every 4 hours). 4. aspirin 325 mg tablet : one (1) tablet po daily (daily). 5. ipratropium bromide 17 mcg/actuation aerosol : two (2) inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. hydromorphone (dilaudid) 0.5-2 mg iv q4-6h:prn hold for sedation, confusion, rr<10 7. acetaminophen 500 mg tablet : one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 8. metoprolol tartrate 50 mg tablet : two (2) tablet po q6h (every 6 hours). 9. pantoprazole 40 mg iv q12h 10. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 11. psyllium 1.7 g wafer : po once a day. 12. atorvastatin 80 mg tablet : one (1) tablet po once a day. 13. cyanocobalamin 100 mcg tablet : one (1) tablet po daily (daily). 14. cholestyramine-sucrose 4 g packet : one (1) packet po bid (2 times a day). 15. glutamine 10 g packet : one (1) packet po daily (daily). 16. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 17. heparin (porcine) 5,000 unit/ml solution : one (1) injection three times a day. 18. levetiracetam 100 mg/ml solution : 1000 (1000) mg po bid (). 19. lorazepam 1-2 mg iv prn for generalized seizure>5min or >3 seizures/hr 20. nitroglycerin 0.3 mg tablet, sublingual : one (1) tablet, sublingual sublingual prn (as needed). 21. opium tincture 10 mg/ml tincture : fifteen (15) drop po q4-6h (every 4 to 6 hours) as needed. 22. loperamide 2 mg capsule : one (1) capsule po qid (4 times a day) as needed. 23. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed for skin redness. 24. acetylcysteine 10 % (100 mg/ml) solution : one (1) ml miscellaneous q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: hospital of and islands discharge diagnosis: primary diagnosis: seizures e. coli uti tracheitis anemia diarrhea eosinophilia hyponatremia weakness elevated psa . secondary diagnosis: peripheral disease congestive heart failure, systolic chronic renal insufficiency discharge condition: wbc count normalized, afebrile. discharge instructions: you were admitted to the neurology service with seizures that required intubation in order to deliver enough medications to control. they are now controlled on keppra alone. you were transferred to the medicine service for further management of your multiple medical problems. . you were treated for infection in you bladder and respiratory secretions. you were found to have an elevated psa of 9 with enlarged prostate and should follow up with your primary care doctor regarding this matter. . please call your doctor or return to the emergency room if you develop fevers, chills, worsening cough/secretions, abdominal pain, worsening of diarrhea, blood in your stool or dark/tarry colored stool, trouble or discomfort urinating or any other symptoms that concern you. followup instructions: 1. neurology: you have an appointment with dr. on at 1:00 pm at the building, . if you have any questions, please call (. . 2. gastroenterology: ( with dr. on at 12pm at . this appointment is to evaluate your diarrhea and anemia. . 3. pulmonary: regarding your prolonged intubation and trach placement and your questions regarding trach reversal. your appoitment is on at 2:30pm in the building () on the . this appointment is with dr. (. . 4. urology: ( at 3pm with dr. in building on on the . this is regarding your enlarged prostate and elevated psa. md, procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung enteral infusion of concentrated nutritional substances temporary tracheostomy transfusion of packed cells transfusion of other serum diagnoses: urinary tract infection, site not specified hyposmolality and/or hyponatremia atrial fibrillation chronic kidney disease, unspecified systolic heart failure, unspecified bacteremia pneumonia due to escherichia coli [e. coli] diarrhea encephalopathy, unspecified cerebral artery occlusion, unspecified with cerebral infarction other and unspecified postsurgical nonabsorption chronic vascular insufficiency of intestine staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified acute tracheitis without mention of obstruction eosinophilia elevated prostate specific antigen [psa] epilepsia partialis continua, with intractable epilepsy infection with microorganisms with resistance to multiple drugs 

Answer: The patient is high likely exposed to