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: tetracyclines / zinc attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation with mechanical ventilation history of present illness: 65 yo f with h/o multiple admissions for aspiration pna now admitted with sob. pt was recently admitted with aspiration pna and r elbow osteomyelitis and was treated with vancomycin and imipenem which then changed to bactrim x 2 weeks. pt found this morning by caregiver s/p fall - was put in bed and went to get meds and came back and pt had fallen again, so pt was brought to ed. of note, pt took all her meds this morning including her atenolol, hx taking a lot of oxycodone. in pt was dyspneic with initial o2sat 68% on ra, t 101. was placed on nrb and sats improved to mid 80%'s, but pt was not alert or oriented. cxr showed improved rll pna compared to . she was intubated and had copious prurulent sputum. pt started to receive a dose of vanco and developed a blotchy rash on l arm and vanco was stopped and benadryl was given. rash began to improve and vanco was restarted. while the vanco was infusing she began to become hypotensive and hr was in the 50's. therefore vanco was d/ced (after approx 1/2 dose given), pt was started on meropenem, and given ivf for bp control. was given a total of 2l ns and sbp improved to low 100's, but she remained with decreased mental status without any sedatives. head ct showed no acute bleed. during head ct, pt became hypertensive and more agitated. propofol gtt was increased and bp decreased to sbp 100. head ct showed no acute bleed, and patient was brought to . past medical history: -castleman's disease since , followed by dr. . hx mediastinal lad. -s/p splenectomy -hx of thyroid cancer as adolescent s/p thyroidectomy and subsequent hypothyroidism -esophageal stricture and dysmotility s/p esophageal dilation -recurrent aspiration pneumonia; last admission , 5/13-5-20; s/p course of imipenem for most recent episode; * sputum culture grew afb* -chronic abnormal lung ct with tree in appearance: nos (plan to reimage in ) -chronic r olecranon bursitis and mrsa osteomyelitis of r olecranon s/p multiple debridement (most recent one on ) -hx of mrsa pneumonia -bipolar disorder with hx of suicide attempt -pvd -htn -gerd, hx perforated ulcer in past -seizure disorder (reportedly had generalized seizure several years ago assoc. with hypoglycemia, none since, no meds) -s/p r hip fracture with failed orif and redo at -hx of grave's dz with ophthalmopathy -osteoporosis -herpes zoster -pft () w/ restrictive pattern: fvc 62% fev1 65% fev1/fvc 105% social history: lives alone. has a visiting nurse that comes for only a few hours each day. or iv drug use. family history: nc physical exam: physical exam: vitals - t 94.5, hr 48, bp 118/43, o2sat 100% on ac/500x22/0.5/8, cvp=13 general - intubated, sedated but easily arousable by calling name. heent - pupils 4-5mm, equal, sluggishly reactive to light b/l neck - l ij in place w/ bandage c/d/i. right neck w/ scar tissue. no noted jvp cvs - bradycardic, regular rate, no noted m/r/g lungs - decreased breath sounds on r base, otherwise vented breath sounds b/l, no noted crackles/wheezes abd - soft, +bs ext - no pitting edema in extremities b/l. some blue discoloration to knee caps b/l. distal le cool to touch b/l - rest of body warm, dry (pt under bear-hugger during exam) neuro - pt opens eyes to calling name, able to follow commands, answer yes/no questions. skin - r ue with bandages around elbow and wrist that appear c/d/i. l ue with ulcerations with red base/clean margins on forearm without signs infection (no surrounding erythema, not warm to touch), scattered ulcerations with red base/clean margins on l le with signs of infection. scars noted on r neck pertinent results: imaging: head ct neg for bleed or intracranial mass effect cxr: rll pna - improved from . cxr later on day of admission demostrates diffuse increased markings consistent with pulmonary edema. 04:29am blood wbc-14.5* rbc-3.14* hgb-9.6* hct-29.5* mcv-94 mch-30.5 mchc-32.5 rdw-15.3 plt ct-548* 03:38am blood neuts-75* bands-2 lymphs-12* monos-6 eos-4 baso-0 atyps-0 metas-0 myelos-1* nrbc-2* 04:29am blood plt ct-548* 04:29am blood glucose-82 urean-18 creat-0.9 na-137 k-5.1 cl-100 hco3-29 angap-13 05:46pm blood ck(cpk)-145* 05:46pm blood ctropnt-<0.01 04:29am blood calcium-10.5* phos-3.6 mg-2.2 brief hospital course: 1) respiratory failure: likely aspiration pna (given history of recurrent aspiration pna esophageal dismotility) complicated by sepsis. other possiblities included aspiration pneumonitis vs (although per dr. , has remained stable, therefore less likely diagnosis) vs pulmonary edema (based on rpt cxr later on day of admission - although unlikely primary cause b/c was not apparent in initial cxr, and no known underlying cause - cardiac enzymes negative x 3, ef = 55%). patient was initially intubated in the ed and was maintained on mechanical ventilation with improved respiratory status in the . cxr showed both rll infiltrate and signs of chf. she was agressively diuresed and completed a 10 day course of vancomycin and meropenem to cover aspiration pna and given her history of mrsa in her rt arm osteomyelitis. etubation was delayed due to sedation. she underwent a successful spontaneous breathing trial on and was subsequently extubated. after extubation she maintained good o2 sats and did not show evidence of respiratory distress. shortly after extubation she was weaned off of supplemental oxygen and was maintaining good o2 saturations on room air. 2) sepsis: pt presented w/ fever to 101 in ed, then to ?hypothermia on presentation to (initial temp 94.5, increased to 97.8 w/ rectal temp using different thermometer - also on bearhugger), wbc to 23.7 with bandemia, hypotension, arf w/ decreased uop. source likely asp pna, as mentioned above vs other source of infection including recurrent osteomylitis of r olecrenon (unlikely as pt has completed abx therapy) vs other source. blood cxs, urine cx, sputum cx, stool all were neg other than yeast that grew out of her sputum. bp maintained w/ fluid boluses prn initially. patient initially given 10 day course of merepenem and vancomycin. she was then switched to bactrim as she had been on this at home for positive mrsa cultures. wbc gradually trended downward. 3) htn: outpatient meds included lisinopril and atenolol. held while hypotensive, septic. htn has improved slightly since adding captopril. current regimen of metoprolol 25mg tid and captopril 75mg tid. previously bradycardic so we were cautious with increasing metoprolol. if need to go up further would consider increasing captopril to 100 tid. 4) arf: pt had cr to 3.3 up from baseline of 0.7. resolved with hydration and currently back to baseline. diuresed well with lasix, now self diuresing. closely monitored creatinine and supplemented self diuresis with lasix with daily i/o goal. 5) anemia: patient has had anemia in the past with hct trending in the high 20's in recent months. closely monitored hct. no evidence of active bleed. 6) acid/base status: has had mixed acid-base disturbances throughout hospitalization. initially had non ag metabolic acidosis at admission (abg 7.23/31/78, ag=10) likely fluid rescusitation. (chloride elevated @ 117). now somewhat alkalemic, with elevated pco2, likely from contraction alkalosis diuresis. 8) right olecranon osteomyelitis s/p treatment with vancomycin + imipenem for 10 day course-> bactrim. area bandaged - appears c/d/i. monitored area during daily exams to check for signs/sxs of infection. dry gauze dressing changes qd as pt has completed a course of anibiotics but with need to follow-up with infectious disease as previously arranged. 9) atypical mycobacteria: pt never been on medication for - stable per dr. who follows pt for this. chest ct does have tree and appearance. considered rx if pt r/o for all other signs of infection and believed to be likely source of sepsis - thought unlikely due to chronice/stable nature. patient to f/u with dr. on d/c 10) castlemans disease: stable, no further workup necessary at this time. will advise f/u w/ pcp on /c 11) hypothyroidism: patient was continued on levoxyl during admission. 12) esophageal dysmotility: stable. known problem by patient and is cause of her recurrent aspiration pna. issue of feeding tube addressed w/ pt in past and patient has refused enteral feeding which she has reiterated after this extubation. she understands the risks of reaspiration and reintubation and is willing to assume those risks in order to eat orally. 13) seizure d/o: none evident during admission. continued on outpatient regimen of lamotrigine and gabapentin. 14) osteoporosis: c/w mvi, vitamin d and calcium carbonate 500mg tid 15) fen: nasogastric tube was placed and patient received tf and goal rate. per caregiver, pt not eating well in recent weeks. nutrition consulted. lytes were monitored and repleted on an as needed basis. patient hdpoor nutritional status and was cachetic appearing. in previous speech and swallow evaluations she is noted to have aspirations. patient has been unable to tolerate a thickened/pureed diet nausea. during previous admissions her teams have discussed the possibility of placing a peg tube and she has refused. patient was again counseled during her icu stay as to the risks for future aspirations and the future need for intubation. she adamantly declined a peg tube and plans to continue po intake. she was also advised to supplement her diet with boost or ensure but she reports that she is unable to tolerate these. medications on admission: 1. trimethoprim-sulfamethoxazole 160-800 mg tablet : one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 2. venlafaxine 75 mg capsule, sust. release 24hr : one (1) capsule, sust. release 24hr po daily (daily). 3. levothyroxine sodium 100 mcg tablet : one (1) tablet po daily (daily). 4. oxycodone 20 mg tablet sustained release 12hr : one (1) tablet sustained release 12hr po q12h (every 12 hours). 5. lamotrigine 25 mg tablet : two (2) tablet po hs (at bedtime). 6. gabapentin 300 mg capsule : one (1) capsule po q12h (every 12 hours). 7. cholecalciferol (vitamin d3) 400 unit tablet : one (1) tablet po daily (daily). 8. benzonatate 100 mg capsule : one (1) capsule po bid (2 times a day). 9. polysaccharide iron complex 150 mg capsule : one (1) capsule po daily (daily). 10. albuterol sulfate 2 mg tablet : two (2) puff po q6h (every 6 hours). 11. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 12. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 13. senna 8.6 mg tablet : two (2) tablet po hs (at bedtime). 14. zolpidem tartrate 5 mg tablet : two (2) tablet po hs (at bedtime) as needed for trouble sleeping. 15. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 16. lisinopril 30 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 17. atenolol 100 mg tablet : one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 18. humibid la 600mg po bid discharge disposition: extended care facility: & rehab center - discharge diagnosis: aspiration pneumonia chf discharge condition: stable on room air discharge instructions: if you experience any increasing cough, fever, chills, shortness of breath, you should call your doctor but if no doctor is available you should go back to the emergency room. we also changed your blood pressure medications which you should take as prescribed. followup instructions: you should follow-up with a primary care doctor within the next 1-2 weeks for post hospitalization follow-up. provider: scan where: radiology phone: date/time: 10:00 provider: /dr where: medical specialties phone: date/time: 2:30 provider: , md where: medical specialties phone: date/time: 1:20 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization systemic arterial pressure monitoring diagnoses: acidosis esophageal reflux unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia severe sepsis infection with microorganisms resistant to penicillins other convulsions peripheral vascular disease, unspecified anxiety state, unspecified acute respiratory failure other specified cardiac dysrhythmias hypotension, unspecified pneumonitis due to inhalation of food or vomitus alkalosis methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site osteoporosis, unspecified enlargement of lymph nodes bipolar disorder, unspecified postsurgical hypothyroidism personal history of malignant neoplasm of thyroid dyskinesia of esophagus pulmonary tuberculosis, unspecified, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture chronic osteomyelitis, forearm 

Answer: The patient is high likely exposed to