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: penicillins attending: chief complaint: transferred from for respiratory failure major surgical or invasive procedure: arterial line placement picc line placement intubation history of present illness: pt is a 62 yo male with history of lung cancer (s/p rul lobectomy), copd o2 dependent (3 l), history of mrsa and psuedomonal pna who is a transfer from . per ems notes, last night they were called to patient's house for difficulty breathing which had been ongoing for 45 minutes. he was found to be sitting up in bed in stridorous and diaphoretic. he was unable to speak; albuterol neb treatments were tried without much success. he was brought to where he was admitted to the icu and started on bipap, iv solumedrol, and levaquin. he required increasing amounts of o2 on bipap and was tachypnic in the 30s. 7.30/45/63 on 60% bipap with o2 90%. pt was intubated at 7:40 am on day of admission and transferred to . bp 219/90 per report, hr 90-136. post-intubation he was give 8 mg iv dilaudid, 4 mg ativan, 150 mcg fentanyl, 2 mg versed, and nitropaste. also received fentanyl in med flight though records unavailable now. pt was hospitalized at for shortness and breath and copd exacerbation. he was given prednisone and levaquin. most recent hospitalization at was in for when he had a pneumothorax from his severe emphysema. prior to that, in patient was in the icu at for mrsa and psedomonal pneumonia. the patient received linezolid for a 21 day course for mrsa pna and cefepime for 21 day course for pseudomonas. amikacin was added for synergy. this was all in the setting of a three week prior hospitalization for copd/pna with sputum growing mrsa and pseudomonas treated with bactrim and levaquin. past medical history: 1. non-small cell lung cancer, s/p r upper lobectomy, partial r fifth rib resection c/b chronic pain. no chemo or radiation. 2. copd w/ severely reduced dlco, fev1 42%, and fev1/fvc ratio 59%; stage= moderate iib 3. h/o mrsa and pseudomonas pna 4 ulcerative colitis - s/p multiple surgeries, most recently in late 80s. s/p total colectomy and ileostomy 5. steroid induced hyperglycemia 6. pfo 7. h/o cardiomegaly 8. h/o depression 9. spirometry actual pred %pred fvc 2.87 4.01 72 fev1 1.21 2.86 42 mmf 0.70 2.87 24 fev1/fvc 42 71 59 lung volumes actual pred %pred tlc 6.19 6.12 101 frc 4.59 3.42 134 rv 4.09 2.12 193 vc 2.10 4.01 52 ic 1.60 2.70 59 erv 0.50 1.31 38 rv/tlc 66 35 191 he mix time 0.00 dlco actual pred %pred dsb 6.62 25.62 26 va(sb) 4.46 6.12 73 hb 12.70 dsb(hb) 7.02 25.62 27 dl/va 1.58 4.19 38 social history: married, 2 daughters, lives on the . not current smoker, quit in w/ dx of lung cancer, 40 pack-yr history. occasional etoh use. worked as a paiting contractor, retired after lung cancer surgery. family history: f died of lung cancer; m died of alzheimer's. has 3 sisters, all older than him, healthy physical exam: initial physical examination: vs: t: 95.0, bp: 94/55, hr: 64, ac 500/12/100/5 breathing at 15. o2: 94% gen: intubated, sedated heent: pinpoint pupils reactive 2-->minimal. sclera anicteric. ett in place. neck: no lad. no jvp at 30 degrees. cv: rrr s1s2. no m/r/g lungs: diffuse rales and rhonchi bilaterally anteriorly. scattered wheezes anteriorly. abdomen: +colostomy bag in place. many surgical scars bilaterally in lower abdomen. soft, nondistended. ext: no edema. dp 2+. pt 2+ neuro: cannot follow commands nor arouse. biceps, brachio reflexes . patellar reflexes . babinski equivocal. pertinent results: labs on admission: 11:52am blood wbc-6.2 rbc-3.62*# hgb-10.3*# hct-31.7*# mcv-88 mch-28.4 mchc-32.3 rdw-15.7* plt ct-244 11:52am blood neuts-73* bands-14* lymphs-2* monos-5 eos-0 baso-0 atyps-0 metas-6* myelos-0 11:52am blood pt-12.8 ptt-28.7 inr(pt)-1.1 11:52am blood glucose-243* urean-33* creat-1.3* na-145 k-6.1* cl-113* hco3-21* angap-17 11:52am blood alt-10 ast-10 ld(ldh)-169 alkphos-66 amylase-117* totbili-0.3 11:52am blood albumin-3.0* calcium-7.8* phos-4.8* mg-1.4* 12:16pm blood type-art rates-12/ tidal v-500 peep-5 fio2-100 po2-86 pco2-59* ph-7.17* caltco2-23 base xs--7 aado2-590 req o2-94 -assist/con intubat-intubated labs on discharge: 04:52am blood wbc-9.9 rbc-3.46* hgb-9.7* hct-29.5* mcv-85 mch-28.0 mchc-33.0 rdw-16.6* plt ct-250 04:52am blood neuts-65 bands-3 lymphs-21 monos-5 eos-2 baso-0 atyps-0 metas-3* myelos-1* 04:52am blood pt-11.0 ptt-29.7 inr(pt)-0.9 04:52am blood glucose-155* urean-23* creat-0.7 na-138 k-4.2 cl-98 hco3-32 angap-12 04:48am blood alt-9 ast-11 ld(ldh)-187 alkphos-76 totbili-0.2 04:52am blood calcium-8.9 phos-2.3* mg-2.2 other labs: 04:48am blood caltibc-256* vitb12-690 folate-8.6 ferritn-304 trf-197* 11:52am blood tsh-0.98 ___________________________________________ microbiology: sputum - **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. moderate growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. pseudomonas aeruginosa. sparse growth. sensitive to amikacin (<=2mcg/ml). pseudomonas aeruginosa. sparse growth. second colonial morphology. sensitive to amikacin (<=2). sensitivities: mic expressed in mcg/ml _______________________________________________________ staph aureus coag + | pseudomonas aeruginosa | | pseudomonas aeruginosa | | | cefepime-------------- 2 s 2 s ceftazidime----------- 4 s 4 s ciprofloxacin--------- =>4 r =>4 r clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s =>16 r =>16 r imipenem-------------- =>16 r =>16 r levofloxacin---------- =>8 r meropenem------------- 4 s 4 s oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- <=4 s 8 s piperacillin/tazo----- 8 s <=4 s rifampin-------------- <=0.5 s tetracycline---------- 2 s tobramycin------------ =>16 r =>16 r vancomycin------------ <=1 s blood culture - no growth legionella urine ag - negative sputum gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): multiple organisms consistent with oropharyngeal flora. respiratory culture (final ): moderate growth oropharyngeal flora. gram negative rod(s). rare growth. - urine culture- no growth blood culture x 2- no growth _______________________________ radiology: echo aortic valve - peak velocity: 1.3 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 0.6 m/sec mitral valve - a wave: 0.9 m/sec mitral valve - e/a ratio: 0.67 mitral valve - e wave deceleration time: 151 msec tr gradient (+ ra = pasp): *40 to 45 mm hg (nl <= 25 mm hg) left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: lv not well seen. cannot assess lvef. right ventricle: normal rv chamber size and free wall motion. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. tricuspid valve: normal tricuspid valve leaflets. normal tricuspid valve supporting structures. mild tr. moderate pa systolic hypertension. pericardium: no pericardial effusion. general comments: contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-valsalva maneuver. suboptimal image quality - poor echo windows. suboptimal image quality - poor parasternal views. suboptimal image quality - poor apical views. suboptimal image quality - poor subcostal views. conclusions: the left atrium is normal in size. the left ventricle is not well seen. overall left ventricular systolic function cannot be reliably assessed. right ventricular chamber size and free wall motion are normal. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. bubble study did not demonstrate any clear right-to-left shunting at the atrial level, but image quality is suboptimal. compared with the findings of the prior study (images reviewed) of , the findings are grossly similar but the technically suboptimal nature of both studies precludes definitive comparison. . other radiology: cxr ap-nasogastric tube and endotracheal tube have been removed. cardiac silhouette appears larger than on the prior study and is accompanied by engorged pulmonary vessels and perihilar haziness, attributed to either chf or volume overload. these findings are superimposed upon extensive emphysema, post-operative changes in the right upper lobe, and extensive areas of parenchymal scarring. persistent left retrocardiac opacity, likely due to a combination of atelectasis and effusion, although underlying infection is not excluded in the appropriate clinical setting. cxr ap-findings: et tube has been repositioned in the interval, and now terminates 5.7 cm above the . the ng tube still is in a suboptimal positioning with the side port well above the expected location of the ge junction. overall, the appearance of the chest is unchanged from today's radiograph, including status post right upper lobectomy with associated right-sided volume loss, opacities projecting over the right medial and lower hemithorax. there is no evidence of pulmonary edema. small left-sided pleural effusion and left lower lobe atelectasis is unchanged. impression: 1. interval repositioning of the et tube, now terminating 5.7 cm above the , be advanced 1-2 cm for more optimal placement. 2. malpositioned nasogastric tube. brief hospital course: impression/plan: 62 yo male with copd on home o2 (3l), history of lung cancer, history of multiple pnas (including mrsa) who is a transfer from for respiratory failue and intubated. 1. respiratory failure- pt with severe emphysema/copd. cxr with showed a possible rml opacity and left pleural effusion. we started solumedrol 80 mg iv q12 hours. we initially started patient on vancomycin for possible mrsa and cefepime to cover gnr and pseudomonal species. sputum culture grew out mrsa (moderate growth) and pseudomonas (sparse growth) resistant to fluroquinolones (see attached micro data). additionally, blood cultures from grew out 2/2 bottles of streptococci pneumoniae sensitive to levaquin and penicillin. patient was successfully extubated on . additionally, combivent nebs were given around the clock while patient was vented. this was changed to tiopropium, fluticasone-salmterol, and albuterol when he was extubated. after extubation, patient was able to get to 6 l of nc and satting in low-mid 90%. however, whenever he was turn or exert himself in any manner, he would desaturate to as low as 70%. he would correct and return to oxygenating in the 90s after a few minutes. to further investigate this and to look for a shunt, a tte was done, as one from showed a patent foramen ovale and right to left shunt but only when he maneuvered himself. a repeat bubble study echo on the day of discharge was suboptimal in quality. it showed moderate pulmonary artery systolic hypertension but no right-to-left shunting at the atrial level. steroids were changed to prednisone after extubation and have been slowly tapered to 60 mg and patient is on 40 mg prednisone (day 2) on discharge. the plan will be for a two week steroid taper to usual dose(patient is on 10 mg po prednisone at home). he received a 10 day course of vancomycin (last day was day of discharge) for mrsa in sputum (? source of pneumonia). also was initially on levaquin which was changed to cefepime, plan for a 14 day course. 2. copd- as above. he has severe emphysema by dlco. medications as above. 3. bacteremia- as above. blood cultures at the outside hospital grew strep pneumonia. he was on levaquin which was changed to cepepime as above. 4. hypertension- initially on arrival to pt was hypotensive and required fluid boluses, though never required pressors. he had received dilaudid, fentanyl, ativan, and other medications including nitropaste post-intubation. his blood pressures subsequently came up. in fact, patient was hypertensive here in the 160s systolic post-intubation. captopril was started and uptitrated to 25 mg tid; we then changed him to lisinopril 20 mg to be started the am after discharge. 5. chronic pain- patient has a history of chronic pain, mainly in lower back (also right ribs. we increased his oxycontin to tid dosing (20 mg tid). he required iv dilaudid for breakthrough pain. 6. steroid induced hyperglycemia- required ~30 units of insulin per day on day of discharge. he was initially on a regular insulin sliding scale. on dischare, he was changed to lantus pm with a humalog sliding scale. insulin will need to be adjusted at rehab. 7. f/e/n- got tube feeds while intubated. then was on a regular diet. nutrition saw patient and recommended ensure sedondary to nurtitional needs. 8. ppx- heparin sc and ppi while intubated 9. code- full medications on admission: medications at home (per ): neurontin 300 mg po tid spiriva 1 puff qday prednisone 10 mg po qday paroxetine 20 mg po qday oxycontin 20 mg po bid medications on transfer to : solumedrol 125 mg iv q 6 hours combivent nebs q4 hours paroxetine 20 mg po qday oxycontin 20 mg po bid neurontin 300 mg po tid levaquin 500 mg po iv qday albuterol nebs q2 prn ativan 1 mg iv qhs prn morphine 2 mg iv q2 prn dilaudid 8 mg iv x 1 am on admission versed 2 mg iv x 1 nitropaste 1 inch at 8:25 am morning of admission discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours) as needed. 2. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). 3. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. prednisone 20 mg tablet sig: two (2) tablet po daily (daily) for 2 days: last dose . 6. 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. 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 8. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 9. prednisone 20 mg tablet sig: one (1) tablet po once a day: to start . tablet(s) 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po bid (2 times a day). 11. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 12. oxycodone 20 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q8h (every 8 hours): hold for sedation or rr<8. 13. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 14. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 16. hydromorphone 2 mg/ml syringe sig: 0.5 - 2 mg injection q4h (every 4 hours) as needed: hold for sedation or rr<8. 17. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 18. cefepime 2 g recon soln sig: one (1) recon soln injection q12h (every 12 hours): last day . 19. insulin lantus 10 units qhs with humalog insulin sliding scale 20. oxygen on 6l nc on discharge discharge disposition: extended care facility: northeast - discharge diagnosis: primary diagnosis: respiratory failure s/p intubation chronic obstructive pulmonary disease pneumonia hypoxia hyperglycemia hypertension bacteremia secondary diagnosis: chronic pain discharge condition: patient's vital signs are stable. his oxygenation is 90-95% on 6l nc and cool nebs. he desaturates when discharge instructions: microbiology needs to be called to follow up on pending cultures in the hospital. followup instructions: you should call your pulmonologist, dr. for follow up. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances arterial catheterization diagnoses: unspecified essential hypertension personal history of malignant neoplasm of bronchus and lung obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure bacteremia ostium secundum type atrial septal defect methicillin susceptible pneumonia due to staphylococcus aureus ulcerative colitis, unspecified streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified 

Answer: The patient is high likely exposed to