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: sulfa (sulfonamides) / cephalosporins attending: chief complaint: transfered here for epicardial abscess management major surgical or invasive procedure: intubated, r-scv placed, a-line, pacer wire placed, picc line history of present illness: 65 y.o. m with steroid dependent copd/asthma, recurrent pulmonary infections due to mrsa/pseudomonas, s/p transferred from on with endocarditis and complete heart black with temporary pacer with no escape rhythm. . patient was admitted to on with presumed copd exacerbation and chf. overnight he became more tachypnic with hypercarbic respiratory failure and was intubated in the morning of . he was also found to have second paused and responded to atropine. patient was also hypotensive to 80s during the episode and then recovered to sbp of 100s. patient was also found with with 3:4 wenckebach rhythm varying with mobitz pattern rhythm, then paf with tachyarrhythmia 1-teens, with 4-5 second pauses. tee was performed on . he went into patient was found to be in in complete heart block. luckily, by that point he had a single temporary v wire inserted through r ij on . since then patient with no escape rhythm. . patient has severe undelrying copd (fev1 0.79) requiring chronic high dose steroids. he was started on high dose solumedrol at . patient was also found to be bacteremic with mrsa bcx upon initial admission with less than 24 hours, started on vanco and levo. gentamycin was added the next day for synnergy. patient also with 4/23 gnr in his sputum. patient was recently treated for mrsa bacteremia and sepsis back in . presumed source was iv thrombophlebitis. patient was also found to have lung septic embolic. patient underwent 6 week course of vanco iv and 4 week of linezolid (for presumed improved pulmonary penetration). repeat ct on showed improvement of pulmonary cavitations on chest ct. . patient was transfered to for further management. on the morning of transfer patient with hct from 33 to 27 with minimal coffee ground emesis and guiac positive stools. hct appears to be stable @ 27 upon repeat. ros: upon arrival to ccu, patient is intubated, he stays he is in mil pain. he denies any cp, sob. no fevers/chills. communication is limited due to intubation but he appears lucid. past medical history: # no known cad # htn # copd - fev1 .79 ~ 29%, requiring persistent high dose steroids and mulitiple admission to / rehab. co2 33 on with ph of 7.39, co2 63, po2 74, hco3 38, sats 94%. # multiple cavitary lession- nos - in lungs after mrsa skin infection in , appears to be improved # mrsa septicemia - from iv line tx with vanco 6 weeks, then linezolid x 4 weeks with septic emboli to the lungs. # pseudomonas in sputum # cervical disk disease - c4-5 discectomy - chornic management with moderate narcotics # ? epidrual abscess or a large disk herniation - due to complain of increased neck pain detected on mri on ---- repeat ct on showed no evidence of epidural mass although a small epidural abscess may not be excluded if very small and unable to be picked up by ct resolution ---- c3-c4 small posterior protrusion, also mild dorsal bulging consistent with degenerative narrowing of c5-c6 narrowing of left c6 foramen, same @ c6-c7. # chronic hepatitis c -s/p succesful ifn therapy 8 years ago # chronic anemia - # multiple surgeries including ventral hernia repair s/p bullet wound in 20s. # chronic anxiety and depression # nl renal function - cr 0.7 upon admission to # recurrent epistaxis - s/p septal repair - thus no anticoagulation social history: shx: h/o tobacco, no etoh. no ivdu. chronic narcotic use. lives alone. single. . family history: fhx: emphysema in mother, no other known cad physical exam: vitals: wt 61.5 97.1 hr 60 bp 102/60 rr 15 100% gen: awake, frail, elder gentleman, ett, nad heent: anicteric, left inferio-medial conjuctival hemorrhage, mm dry, r ij cordis with pacer wire, no jvd appreciated on l side, neck: no adenopathy cv: rrr, nl s1, s2, unable to appreciate murmur given increased ap diameter of chest. chest: diffuse rales, no wheezes, no crackles, mechanical breath sounds, barrel chested. abd: + bs - faint, snt/nd, no masses ext: no edema, no cyanosis, no clubbing skin: both hand (palms) and feet(soles) with osler nodes and lesions. vasc: + 1 dp b/l pertinent results: labs: from osh: bcx x 2 - total 6 cultures, each day + for mrsa sputum: gnr, staph 146/4.4 109/32 45/0.8 ca7.7 alb 1.5 tprot 5.5 tbili 1.8 dbili 0.8 alkphos 117 alt 67 ast 85 wbc 16k 22% b -> 22.2 -> 16.3 -> 13.7 @ hct 33 -> 27.2 plt 112 trop 0.52 -> 0.49 -> 0.71 bnp 756 . labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 05:04am 17.1* 3.84* 10.8* 32.4* 84 28.1 33.4 19.1* 91 12:30pm 13.7* 3.29* 8.6* 28.9* 88 26.2* 29.8* 16.3* 90 neuts bands lymphs monos eos baso atyps metas myelos 12:30pm 95* 3 0 2 0 0 0 0 0 . glucose urean creat na k cl hco3 angap 05:04am 120* 23* 0.4* 136 3.7 100 32 8 . hemolysis labs: fibrino fdp d-dimer 03:17pm 40-80 06:02am 40-80 06:02am 132* 2753 . alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 03:17pm 438* 2.2 hapto 03:17pm 25 . hepatitis: hcv ab 05:09pm positive 5:09 pm immunology source: line-aline. hcv viral load >700,000 iu/ml. . micro: sputum: *final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. moderate growth. . sputum: 5:09 pm sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (preliminary): oropharyngeal flora absent. pseudomonas aeruginosa. moderate growth. staph aureus coag +. moderate growth. . bcx: 12:10 pm blood culture random. **final report ** aerobic bottle (final ): reported by phone to at 7:00 am. pseudomonas aeruginosa. . bcx: no growth . bcx: 6:34 pm blood culture **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): staph aureus coag +. . 5/2bcx: 5:22 pm blood culture aerobic bottle (preliminary): staph aureus coag +. final sensitivities. oxacillin resistant staphylococci 5/3bcx: pending . : tee: large mobile anterior leaflet mitral valve vegetation with leaflet perforation and moderate-severe mitral regurgitation. echolucent space consistent with an abscess in the interatrial septum posterior to the aortic root and color flow consistent with fistulous connection into the right atrium. smaller mobile vegetation on the tricuspid valve. . : ct head: two small foci of increased density within the right frontal lobe. the study is limited by the lack of a non-contrast acquisition, however, these findings could represent enhancing vessels versus small foci of extra-axial hemorrhage or cortical enhancement. . : ct neck: multiple cavitating and noncavitating pulmonary nodules at the right and left lung apices, and bilateral pleural effusions. the findings are consistent with septic emboli. no definite evidence of epidural abscess. . : chest ct: impression: 1. numerous nodular opacities throughout the lungs, many of which are cavitary consistent with septic emboli. the largest is within the right middle lobe measuring 3.6 x 3.0 cm with an air-fluid level. 2. small bilateral pleural effusions. 3. striated, hyperdense nephrograms bilaterally concerning for renal failure. . ruq us: findings: multiple small 3-5 mm likely polyps are present within the gallbladder. no stones are identified. the gallbladder wall is mildly thickened measuring 5 mm. there is moderate ascites in the right upper quadrant. no shadowing gallstones are identified. the common bile duct is not clearly identified, and thus is likely not dilated. the proximal pancreas is normal. impression: edematous gallbladder wall likely secondary to third spacing. no gallstones identified. right upper quadrant ascites. . cxr: portable semi-upright chest radiograph: the endotracheal tube is seen at the thoracic inlet. the carina is not well visualized. there is no significant change in positioning compared to prior study. pacer wire is again noted and unchanged. right-sided picc line tip is seen within the distal svc. again noted are multiple bilateral cavitary opacities (better seen on recent ct), consistent with multifocal infection and possible septic emboli that are unchanged compared to prior. brief hospital course: a/p: 65 y.o. m with severe steroid dependent copd, recent mrsa cellulitis in with pulmonary septal emboli/cavitations, myocardial abscess, mv vegetation, lessions and mrsa bacteremia, intubated for increasing tachypnea and hypoxia. . # valves/mitral valve: mrsa bacterial endocarditis w/paravalvular abscess, vegetations - seen on tee with myocardial abscess. pt had evidence of septal emboli in conjuctivae, fingertip, lungs, spleen, spine, and 2 foci in brain. pt did not have any neurological deficits and no signs of hemorrhage in brain. he was closely followed by id. he was started on vanc and completed 5 days of gentamycin for abx synergy. his blood cultures cleared from as well as remained afebrile. his blood cultures were followed daily, his wbc fluctuated without any specific pattern but remained elevated. ct was following pt for possible surgery but the following concerns for sugery included; 1. inability to suspend new valve, 2. persistent bacteremia 3. lack of chf or urgency for surgery 4. septic emboli 5. poor pfts 6. gib. per the brother, if surgery was a possibility then to proceed with surgery. however, per the pt he did not want any heroic measures. there was a tentative plan for or on , awaiting for brain foci to mature, improve his nutrition as his albumin was 1.5. multiple discussions were had with ct surgery, dr. , dr. regarding surgical intervention. on there was a discussion with the pt whom did not want to proceed with surgery, and did not want to be intubated. the pt understood completely that without the surgery he would die. the pt was adamant that he did not want to proceed with the surgery nor remain intubated. the pt was lucid and it was agreed upon with the brother and medical team to proceed with extubation. the pt expired the following morning on at 6am. . . # rhythm/complete heart block - patient with complete heart block; initial presentation was with tachy/brady arrythmias, pacer wire placed for severe bradycardia w/ intermittent block-->eventual chb. wire place . transition from ems pacer to ccu pacer showed evidence of chb w/o escape rhythm. - paced @ 60, no issues, per id will leave temporary wire in - ep: s/p screwed in r v - vvi wire with external rscl pacer - . on day of extubation the pt had many episodes of pacer not capturing in setting of respiratory distress. . # pump - patient with no h/o chf, per prelim echo appears to have nl ef with +1mr, echo here showed + 3 mr. pt did not have any evidence of fluid overload. captopril 6.25 tid to help with mr, however it was held on several occasions for hypotension. . # cad - patient with + troponins, flat cks and no ischemic ekg changes@ osh, peak ck 24, peak trop .71, most likely due to myocardial abscess and associated myocardial necrosis. no asa was given in the setting of gib and possible surgery. he was not on lipitor, bb, and ace as no prior known disease. . # respiratory failure - most likely due to severe underlying copd, ?flair. currently intubated due to respiratory distress (tachypneic to 40, shallow breathing, tiring out): hypercarbic respiratory failure (per abg). pt was kept intubated for >10days. pulmonary was consulted in setting of possible extubation. he was maintained on steroids and weaned to 10mg prednisone daily. he was also found to have pseudomonas in his sputum and treated w/10days of aztreonam. he continued to show psuedomonas in his sputum cultures following aztreonam treatment. however, pt requested to be extubated. on post extubation, pt eventually had respiratory distress, his o2 sats dropped to 70s and expired early morning on . . # mrsa bacteremia - primary bacteremia vs secondary bacteremia from pulmonary cavitation vs ? epidural abscess. pt was continued on vanco with 6 days of gent synergy. daily surveillance cultures were followed, as well as fever curve and wbc. endocarditis as mentioned above. on started to have fevers, his a line was resited, his picc was kept in place as difficulty with access and possible interference with pacer wires. plan for picc line removal when bcx returned as started to have new + blood cultures from . however, pt shortly expired post extubation on in am. . # ? epidural abscess - patient evaluated by ir @ , it may be one of the sources for recurrent septicemia. percutaneous c&s of pre-vertebral abnormality @ c5 was enteretained. however, patient is very high risk and there is no neurological involvement. also, previous mri w/o evidence of abscess, ct of cervical vertebrae could not exclude a small epidural abscess. repeat ct showed no clear evidence in c3-4, but ? of abscess in l4 region. as there was no neurological deficits and given his more pressing mv endocarditis no further w/u for spine done. continued iv vanco. . # anemia - patient with admission hct of 33, this am with a drop to 27.2 of almost 6 points. hct here of 28.9. ngt with minimal coffee grounds initially that resolved. he had a few episodes of brbpr as well as ~200cc blood from ett. he received 2 uprbc as well as a bag of platelets. stool were grossly positive for ocult blood. gi was consulted and advised to stop asa, protonix iv bid. he was ruled out for a retroperitoneal bleed with ct on . his hct was followed closely. hemolysis labs were checked and showed a mild dic picture, but no schistocytes, stable plts. heme was consulted for persisten thrombocytopenia. most likely etiology was poor synthetic function rather than dic picture or loss. heme recommended supportive care as needed with clotting factors in setting of bleeding. pt remained hd stable and did not require further transfusions beyond . . # hypernatremia - patient appears dehydrated with free water deficit of 2.4l - give 1/2 ns x 2l over next 24 hours - high bun with high bicarb suggest contraction alkalosis as well vs. baseline given severe copd. his hypernatremia resolved. . # elevated inr - to old hepc, vs malnutrition (alb 1.2) vs. current levo, vs infiltrative/embolic liver disease, vs recently started statin - d/c statin, continue to follow, reverse if needed for procedures with ffp, ivf - vitamin k 10mg x1 on - improving inr - nutrition consult . # hcp - : . # dnr medications on admission: prednisone 10 mg qd albuterol nebs spririva 18 mcg qd fentanyl 50 mcg q72 ativan 0.5 mg po bid kcl 20 mg qd advair 500/50 1 puff ranitidine 150 mg qd percocet 3/325 1 tab po tid vitamin d 50,000 po qwk . from : methylpred 40 mg iv q8 vanco 1 gm q12 levquin 500 mg iv qd gentamicin 60 mg iv q8 lipitor 80 qd fentanyl patch 50 mcg every 72 hrs protonix 40 iv qd ecasa 325 ntp 0.5 discharge medications: none discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: n/a followup instructions: n/a procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances insertion of temporary transvenous pacemaker system arterial catheterization transfusion of packed cells transfusion of platelets diagnoses: thrombocytopenia, unspecified unspecified essential hypertension long-term (current) use of steroids chronic hepatitis c without mention of hepatic coma acquired coagulation factor deficiency severe sepsis infection with microorganisms resistant to penicillins obstructive chronic bronchitis with (acute) exacerbation methicillin susceptible staphylococcus aureus septicemia acute respiratory failure atrioventricular block, complete pneumonia due to pseudomonas blood in stool septic shock abscess of lung pressure ulcer, lower back acute and subacute bacterial endocarditis embolism and thrombosis of other specified artery ulcer of heel and midfoot septicemia due to pseudomonas psoas muscle abscess degeneration of cervical intervertebral disc cerebral embolism without mention of cerebral infarction 

Answer: The patient is high likely exposed to