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: amoxicillin / glipizide / ciprofloxacin / bactrim / soriatane / potassium chloride / bupropion / calcium channel blocking agents-benzothiazepines / atenolol attending: chief complaint: altered mental status major surgical or invasive procedure: left ij central catheter right arterial line history of present illness: ms. . is a 66 year-old woman with history of diastolic chf, stage 1a nsclc, copd, presenting to the emergency room with cough and dyspnea. ms. . has frequent dyspnea at baseline, but over the past four days patient had noted increased shortness of breath and ocugh. she was supposed to have an endoscopy done last thursday but it was cancelled because she was complaining of cough and dyspnea and anesthesia was not available for the procedure. she has been taking her home dose of toresemide, but has noted decreasing urine output over the past day. she has not been eating or drinking as much at home as she typically does. denies fevers or chills. this morning her daughter noted that she had a low grade fever of 100 and seemed more confused. fs was 119 at that time. she was also complaining of worsened dyspnea, so she called 911. of note patient was last hospitalized in either or , but has not been hospitalized in the last month. her daughter, who she lives with, has also been sick at home over the past week and also has a bad cough. in the ed, initial vs were: 99.6 68 126/59 28 100% non-rebreather. on arrival exam was significant for b/l wheezing and the patient was slightly confused. labs were significant for creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, bnp 3247 (last was 900 in ), leukocytosis to 11.6. abg was 7.3/56/69 - last abg in was 7.44/38/66. cxr with low lung volumes, known-stable rll mass, and concern for right mid-lung pneumonia. patient required bipap while in the ed. in the ed patient received albuterol and ipratripium nebs, nitroglycerin 0.4 mg sl x1, methylprednisolone 125 mg iv x1, azithromycin 500 mg iv x1, and ceftriaxone 1 gram iv x1. on arrival to the micu, patient is on bipap. she is lethargic, but opens her eyes to her name. patient nods that her breathing feels better on the bipap. she denies any pain. past medical history: s/p left lower lobectomy () for mass - pathology returned as a 2.0 cm undifferentiated large cell carcinoma, pt1an0mx, neg nodes clear margins, stage 1a. currently followed by thoracic surgery for spiculated rll lesion, which has increased in size and is concerning for malignancy. - diastolic chf (also with mild mr, as) - a. fib on coumadin - cirrhosis (likely nash vs. congestive hepatopathy) - dmii c/w peripheral neuropathy - pansenitive e.coli uti - c. diff currently on fidaxomicin - copd - chronic venous insuffiency le cellulitis - depression - anemia baseline hct 28.7 - hld - gastritis - nephrolithiasis - psoriasis - history of choleycystectomy - obesity - osteoporosis - hypercholesterolemia social history: lives with daughter. retired file clerk in a law office. current smoker 1 to 1.5 ppd (60 pack year history). no alcohol or illicits. ambulates with a cane because walker doesn't fit well in hallways. family history: +fh for diabetes, no fh for malignances physical exam: admission physical exam vitals: t: 100.8 bp: 110/51 p: 71 r: 14 o2: 100% on bipap (30% fio2) general: lethargic, but arousable to voice, on bipap heent: sclera anicteric, perrl, psoriasis on scalp neck: supple, unable to assess jvp 2/2 habitus cv: regular rate and rhythm, s1, s2, no murmurs appreciated lungs: diffuse rhonchi anteriorly, no rales or wheezes. abdomen: obses, soft, non-tender, non-distended, bowel sounds present gu: foley catheter in place ext: erythema of lower extremity b/l likely consistent with chronic venous stasis changes, 1+ pedal edema, 1+ dp pulses, neuro: lethargic, arousable to voice, follows simple commands, perrla, reflexes symmetric, asterixis discharge physical exam vitals: wt 77.3kg 98.7, 138/70, 69, 19, 96%2l general: nad, sitting up in bed in nad heent: sclera anicteric, perrl, psoriasis on scalp, subconjunctival hemorrhage obscuring white of the eye on the left, not into the at all neck: supple, jvd 5cm above the clavicle cv: rrr, iii/vi sem at the base and ii/vi holosystolic murmur in the mitral area lungs: crackles way up the bases bilaterally abdomen: obsese, soft, non-tender, non-distended, bowel sounds present gu: foley catheter in place draining clear yellow urine ext: erythema of lower extremity b/l likely consistent with chronic venous stasis changes, 1+ le edema up to knees, 1+ dp pulses, neuro: aaox3. no asterixis, tongue fasiculations pertinent results: admission labs: 09:20am blood wbc-11.6* rbc-3.87* hgb-9.4* hct-30.8* mcv-80* mch-24.4* mchc-30.6* rdw-17.4* plt ct-158 09:20am blood neuts-79.4* lymphs-14.4* monos-5.0 eos-0.9 baso-0.3 09:20am blood pt-17.0* ptt-27.5 inr(pt)-1.6* 09:20am blood glucose-111* urean-51* creat-1.9* na-142 k-4.3 cl-103 hco3-27 angap-16 09:20am blood alt-22 ast-36 ck(cpk)-43 alkphos-133* totbili-0.5 09:20am blood ck-mb-3 probnp-3247* 05:27am blood calcium-8.3* phos-5.6*# mg-1.9 05:10pm blood ammonia-25 09:42am blood type- po2-49* pco2-61* ph-7.27* caltco2-29 base xs-0 comment-green top 09:42am blood lactate-1.5 discharge labs: 06:55am blood wbc-10.8 rbc-4.07* hgb-9.5* hct-31.3* mcv-77* mch-23.4* mchc-30.4* rdw-17.3* plt ct-88* 06:55am blood pt-30.4* ptt-36.7* inr(pt)-2.8* 06:55am blood glucose-130* urean-15 creat-0.7 na-142 k-3.1* cl-98 hco3-42* angap-5* 06:55am blood calcium-9.3 phos-2.7 mg-1.9 urine studies 10:15am urine color-yellow appear-clear sp -1.011 10:15am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 10:15am urine rbc-0 wbc-2 bacteri-few yeast-none epi-0 transe-<1 10:15am urine casthy-260* micro: 7:03 pm sputum source: expectorated. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. staph aureus coag +. rare growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 1 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s legionella culture (final ): no legionella isolated. blood cultures x 2 - negative urine culture - negative brief hospital course: ms. . is a 66 yo female with h/o diastolic chf, copd, stage 1a nsclc (and new concerning rll lesion), presenting with dyspnea, wheezing and altered mental status who was admitted with rml pnuemonia who required intubation secondary to altered mental status and worsening hypercarbia who was found to have an mssa pneumonia, and had chf exacerbation requiring diuresis who was improved respiratory and mental status at the time of discharge to rehab. #right middle lobe mss pneumonia- patient was admitted with cough and new cxr finding of infiltrat in the right middle lobe. she required intubation for hypercarbic respiratory failure and altered mental status and was extubated after 24 hour with no further respiratory decompensation. pt was started on ceftriaxone and azithromycin on admission and completed a 5 day course of this. during this time her sputum culture grew out mssa and the patient was treatd with iv vancomycin from (the course was abridged by 1 day thrombocytopenia that there was concern was secondary to the vancomycin. she was treated with vancomycin even after sensisitivies came back given her penicillin and fluroquinolone allergy, and current cdiff infection did not want to treat with clindamycin. after hte patient was called out of the icu she had no further fevers and a nonproductive cough and had no episodes of respitaory distress. she continued to require oxygen around 98% on 2l nc. #chf decompensation- on admission the patient had evidence fo volume overload with an elevated bnp concerning for chf exacerbation, gvein her underlying pneumonia she was not initially diuresed. after transfer to the floor she was diuresed agressively and responded well to 80mg iv lasix 1-2x/day. her weight at the time of discharge is 77.3kg. she has some mild edema in her lower extremitis on discharge and will likely still require continued diuresis at home. she normally takes 80mg of po torsemide as an outpatient. given that she put out 3l to this when given inpatient and developed a contraction alkalsois with it was decided to decrease the dose of her torsemide to 40mg po qday and her outpatient providers can assess if this should be uptitrated once she resumes her regular home food. she was briefly off of her acei given acute renal failure and low blood pressures and this was restarted at 1/2 of her home dose at the time of discharge. she developed chronic hypokalemia in the setting of diuresis and was started on standing potassium supplements. -discharge wt 77.3kg -decreased po torsemide from 80mg to 40mg once a day -decreased enalapril from 20mg to 10 mg once a day -patient has follow-up with dr. will need repeat chem 7 checked on to assess for electrolyte abnormalities and assess specifically for her bicarb elevation (was 42 at the time of discharge) # altered mental status: likely multifactorial - likely in setting of hypercarbia/copd vs, pneumonia/acute infection vs. metabolic derangements from renal failure. while the patient has a history of cirrhosis she had no signs of encephalopathy on exam and never had asterxis. after transfer onto the floor she continued to be altered and her antidepressives were held and then restarted prior to her discharge. she had a nonfocal exam and had a negative head ct. she was awake and a+ox3 at the time of discharge. # acute renal failure: pt presented with elevated bun/ cr (59/1.9). this was likely secondary to intravascular depletion and she had many hyalnie casts on her admission ua which was consistent with this. this resolved to baseline and cr was 0.7 on discharge. #thrombocytopenia- patient devloped thrombocytopenia during her admission downt o 70 at the lowest and was increasing to 88 at the time of discharge. on review of her medicaitons that she was receiving inhouse she was getting vancomycin and it is likely that the combination of vancomycin and her acute infection lead to this. she was not on heaprin during this admission as she is on warfarin for afib. -patient will need platelet count checked in two weeks after discharge to assure that it is improving or sooner if she has petichiae or concerns for bleeding #afib on warfarin- patient was continued on her warfarin while inhouse. per records she was taking 6.5mg of warfarin as an outpatient, this was decreased to 4 and then when cymbalta was restarted increased to supratherapeutic levels and it was held x 1 day and restarted on the day of discharge to 3mg. -she will need her inr checked on and warfarin dose adjusted then. # recurrent c. diff: patient has had difficult to treat c. diff despite long taper of vancomycin and is now on fidaxomicin on admission. she was asymptomatic during her admission. she was followed by id as an outpatient. given that she was on antibiotics throughout the ocurse of her hospital stay her fidaxomicin was continued. she will need to complete a 10 day course started on as this was the planned course prior to her admission -will continue fidaxamicin until # dm: during her admission her nph was held and she was kept on a sliding scale and her metformin was held. as she started to take in more po her blood sugars were remaining elevated. she nph wa restarted at a lower dose on with improved control. would recommend that the outpatient providers uptitrate as needed and will be the ones to decide whether or not to restart the metformin as an outpatient. -stopped metformin -lowered nph dose 56u down to 25 u -patient was discharged with a sliding scale # psoriasis: continued clobetasol 0.05% ointment. # depression: patient originally had her antidepresents held during her altered mental status and these were restarted prior to her discharge. she continued to have very low energy, decreased appetitte and felt depressed while here. she was seen by social work while inpatient and they recommend that she follow-up with social work in -recommend f/u with the social worker. -mirtazapine was decreased from 30mg to 7.5 during this admission due to exessive sleepiness initially (could be reuptitrated as an outpatient) #gerd: continued pantoprazole 40 mg po daily medications on admission: the preadmission medication list is accurate and complete. 1. clobetasol propionate 0.05% ointment 1 appl tp apply to affected area 2. duloxetine 20 mg po daily 3. enalapril maleate 20 mg po daily 4. fidaxomicin *nf* 200 mg oral planned through 5. nph 52 units breakfast nph 56 units bedtime 6. metformin (glucophage) 1000 mg po bid 7. nadolol 20 mg po bid 8. mirtazapine 30 mg po hs 9. omeprazole 40 mg po daily 10. pregabalin 150 mg po bid 11. torsemide 80 mg po daily 12. warfarin 6.5 mg po daily 13. fluticasone-salmeterol diskus (250/50) 1 inh ih 14. albuterol inhaler 2 puff ih q6h:prn dyspnea 15. aspirin 81 mg po daily discharge medications: 1. aspirin 81 mg po daily 2. duloxetine 20 mg po daily 3. fluticasone-salmeterol diskus (250/50) 1 inh ih 4. nph 25 units breakfast nph 25 units bedtime insulin sc sliding scale using hum insulin 5. mirtazapine 7.5 mg po hs 6. nadolol 20 mg po bid 7. omeprazole 40 mg po daily 8. potassium chloride 40 meq po daily duration: 1 doses hold for k >5 9. enalapril maleate 10 mg po daily 10. fidaxomicin *nf* 200 mg oral planned through 11. torsemide 40 mg po daily 12. pregabalin 150 mg po bid 13. warfarin 3 mg po daily 14. clobetasol propionate 0.05% ointment 1 appl tp apply to affected area 15. albuterol inhaler 2 puff ih q6h:prn dyspnea 16. senna 1 tab po bid:prn constipation 17. ipratropium bromide neb 1 neb ih q6h 18. docusate sodium 100 mg po bid 19. acetaminophen 650 mg po q6h:prn pain do not exceed 3g in 24 hour discharge disposition: extended care facility: at discharge diagnosis: mssa pneumonia decompensated dchf acute kidney injury thrombocytopenia 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: dear ms. , it was a pleasure taking care of you while you were here at . you were admitted to the hospital when you were confused. you were found to have a pneumonia and were in the icu where you were intubated for a day and then improved your breathing status. you completed a course of antibiotics for your pneumonia. you were also having worsening heart failure in the setting of this and required more fluid removal with iv lasix to help your breathing. it will be important to monitor your weight daily after you leave. followup instructions: you should have a follow-up appointment scheduled with your pcp for when you get out of rehab. department: medical specialties when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: pft when: tuesday at 9:00 am department: pulmonary function lab when: tuesday at 8:40 am with: pulmonary function lab building: campus: east best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube arterial catheterization closed [endoscopic] biopsy of bronchus central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified esophageal reflux pure hypercholesterolemia tobacco use disorder congestive heart failure, unspecified cirrhosis of liver without mention of alcohol acute kidney failure, unspecified atrial fibrillation personal history of malignant neoplasm of bronchus and lung acute on chronic diastolic heart failure diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes depressive disorder, not elsewhere classified other and unspecified hyperlipidemia acute respiratory failure alkalosis osteoporosis, unspecified intestinal infection due to clostridium difficile long-term (current) use of anticoagulants methicillin susceptible pneumonia due to staphylococcus aureus obesity, unspecified hyperosmolality and/or hypernatremia other psoriasis venous (peripheral) insufficiency, unspecified shock, unspecified 

Answer: The patient is high likely exposed to