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 / tegretol / dilantin kapseal / heparin agents / benzodiazepines attending: chief complaint: reason for micu admission: chronic ventillation major surgical or invasive procedure: rigid bronchoscopy for y-stent placement rigid bronchoscopy for y-stent removal central venous line insertion sigmoidoscopy history of present illness: mr. (a.k.a. "") is an 86 m with a history of cva with chronic right-sided weakness, seizure disorder subsequent to cva, hypertension now off meds, chf with unknown current lvef (last 75% in ), recent ed visit for urinary retention secondary to urethral stricture who presents for a planned admission for re-evaluation of the airways following y-stent removal at his last hospitalization on . . during his last hospital admission, he was found to have a post-obstructive pneumonia presumed secondary to partial tracheal stent occlusion noted on bronchoscopy. the y-shaped stent was removed and granulation tissue debrided from the left mainstem bronchus. he was then discharged to rehab, where he has been chronically ventillated (his baseline prior to his last admission was ventillation only overnight from 10 pm - 6 am). he is readmitted now for rigid bronchoscopy to assess airway and determine need for replacement airway stent. because he is on the ventillator he requires icu admission. . per rehab paperwork, recent active issues include fevers, thrombocytopenia, edema, diarrhea, and variable mental status. according to his daughter, his baseline functional status prior to his last admission was on ventillator at night only, out of bed to wheelchair in the day though no longer walking (left "good" leg is too weak to support his weight, though he can move his foot), living at home with his wife and full-time nursing aides. he has expressive aphasia since his stroke and at his best can speak only a few words at a time; recently he has had significant secretions when the vent is capped so he has not been speaking, but can nod yes/no to questions and communicate with facial expressions. . ros: given aphasia, complete review of systems is not possible. his aide who is with him and was with him at rehab confirms that he has had recent watery diarrhea, which has been improving since monday. he denies any pain including abdominal pain. denies uncomfortable breathing. past medical history: 1) tracheomalacia, status post stent x 2 with failure secondary to stent migration. status post trach revision . status post t-tube removal on . : silicone y-stent revision and replacement. tracheostomy stoma revision. 2) status post stroke in with tia; right upper extremity weakness resulting. 3) hypertension. 4) seizure disorder. 5) history of mrsa. 6) hemorrhoids. 7) arthritis. 8) depression. 9) history of chf. 10) cri social history: married and lived at home with wife (also with medical problems) with full-time private nursing care prior to this recent hospitalization and stay at rehab. forced to retire in following cva from his work as businessman (had an exxon franchise). has three children; his two daughters and serve as his co-health care proxies; he also has a son involved in his care. he has a remote history of social smoking but never a heavy smoker. no recent alcohol. caregivers provide all adls. prior to this admission, he would occasionally take some puree by mouth for pleasure but tf provide nutrition. family history: nc physical exam: admission vs: temp: 97.7 bp: 128/70 hr:70 rr:21 o2sat 100% on fio2 0.3 gen: appears comfortable, nad, following commands, nodding head yes/no heent: perrl, anicteric, mmm, op without lesions though difficult to visualize back of mouth as patient cannot open fully neck: supple, no jvd resp: diminished bs at left base, referred ventillation noises, no wheeze or rales cv: rr, s1 and s2 wnl, no m/r/g abd: mildly distended, +b/s, soft, nt, no masses or hepatosplenomegaly ext: non-pitting edema of feet and right hand (per aide, unchanged since arriving at rehab). 2+ dp pulses. neuro: able to squeeze hand on left though weak grip. can move left foot though very weak. not moving right side which is baseline. facial droop also baseline. pertinent results: tte : the left atrium and right atrium are moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>65%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is high normal. there is no pericardial effusion. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. moderate mitral regurgitation. moderate tricuspid regurgitation. mild aortic regurgitation. compared with the prior study (images reviewed) of , the multivalvular regurgitation is now seen and there now appears to be lack of atrial systolic function. in the absence of a history of systemic hypertension, these raise the suggestion of an infiltrative process such as amyloid cardiomyopathy. ct a/p 1. proctitis, without evidence of megacolon. 2. multi-segmental collapse of the bilateral lower lobes, with foci of ground glass opacity in the aerated lung, consistent with aspiration or infection. there are associated moderate-sized simple pleural effusions. 3. mediastinal lymphadenopathy, likely reactive. 4. nonspecific renal hypodensities might represent cysts though ultrasound evaluation is suggested for further characterization when clinically appropriate. bronch severe granulation tissue formation at distal end of left limb of the y-stent. thick putrulent secretions sent for microbilogy. y-stent removed without difficulty. 10:10 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): moderate growth commensal respiratory flora. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. gram negative rod(s). sparse growth. pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing confirmed by . gram negative rod #3. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 2 s ciprofloxacin--------- 2 i gentamicin------------ 8 i meropenem------------- 8 i piperacillin/tazo----- 8 s tobramycin------------ <=1 s 6:49 pm bronchial washings **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram positive cocci. in clusters. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): >100,000 organisms/ml. commensal respiratory flora. pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. sensitivities performed on culture # 319-3364s on . klebsiella pneumoniae. ~3000/ml. isolates are considered potential pathogens in amounts >=10,000 cfu/ml. further workup on request only. dr. , s () request for work up on . warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. piperacillin/tazobactam sensitivity testing performed by . proteus mirabilis. ~1000/ml. isolates are considered potential pathogens in amounts >=10,000 cfu/ml. further workup on request only. dr. , s () request for work up on . sensitivity testing performed by microscan. ciprofloxacin (>=2 mcg/ml), sulfa x trimeth (>=2 mcg/ml), meropenem (<=1.0 mcg/ml). stenotrophomonas (xanthomonas) maltophilia. ~1000/ml. sensitive to chloramphenicol (<=8 mcg/ml) intermediate to timentin (64 mcg/ml). ceftazidime , chloramphenicol , timentin sensitivity testing performed by microscan. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | proteus mirabilis | | stenotrophomonas (xanthomon | | | amikacin-------------- 32 i ampicillin------------ =>16 r ampicillin/sulbactam-- =>32 r <=8 s cefazolin------------- =>64 r 16 i cefepime-------------- r 4 s ceftazidime----------- =>64 r <=1 s =>16 r ceftriaxone----------- r <=4 s ciprofloxacin--------- =>4 r r gentamicin------------ <=1 s =>8 r levofloxacin---------- 1 s meropenem-------------<=0.25 s s nitrofurantoin-------- =>64 r piperacillin/tazo----- i <=8 s tobramycin------------ =>16 r =>8 r trimethoprim/sulfa---- <=1 s r <=1 s flex sig: patchy areas of mild erythema and granularity were seen in the rectum. impression: abnormal mucosa in the colon otherwise normal egd to sigmoid colon recommendations: healing proctitis noted likely due to ischemia though distribution unusual. no psudomembranes seen, no mass lesion seen. brief hospital course: 86 m with history of tracheobronchomalacia s/p tracheostomy and stent placement on ventillator overnight at baseline with recent admission for post-obstructive left-sided pneumonia followed by removal of stent who presented for planned rigid bronchoscopy. his hospital course was prolonged by sepsis secondary to pseudomonas pneumonia, illeus and protitis. 1. tracheobronchomalacia s/p y-stent removal : since his prior admission for post-obstructive pneumonia during which his y-stent was removed (see operative report note above), he has been chronically ventillated in rehab. y stent placed under rigid bronchoscopy by ip during admission. patient initially did well on trach mask, but then developed copious secretions concerning for a vap. he was covered with ceftazadine and vancomycin and sputum grew pseudomoas. he progressively worsened (see shock below) and ultimately y-stent was removed in or by ip on without intraoperative complication. mr. remained on the vent for several more days and was aggressively diuresed. he tolerated trach mask on and . 2. septic shock/ventilator associated pneumonia - while in the icu for monitoring after his y-stent placement, mr. developed worsening pulmonary secretions and chest x-ray was concerning for pneumonia/vap. he was started empirically on vancomycin and cefepime. he developed worsening hypotension with transient requirement of pressors. he was aggressively resuscitated with 9l ivf with improvement in blood pressure. cefepime was changed to ceftazadime based on previous sensitivities for pseudomonas. mr. over the course of days. repeat sputum culture grew pseudomonas, klebsiella and stenotrophomonos. the pseudomonas was the only organism that grew with >10,000 cfu. the others were felt to be colonizers. **his 14-day course of ceftazidine will complete on . 2. hematachezia - on hospital day 4, mr. was found to have hematachezia. his hematocrit was stable. in the presence of dilated bowel loops on kub and grimmacing to abdominal palpation; surgery was consulted for concern of obstruction vs. other acute process. he was placed on bowel rest. ct abdomen and pelvis showed no obstruction, concern for proctitis. he had a flexible sigmoidoscopy which showed resolving proctitis, perhaps secondary to ischemia. there was no active bleed and no psuedomembranes. c. diff swab was negative x 3. symptoms were most likely proctitis and associated ileus. 3. history of c. diff - recent diarrhea at reheab, c. difficile culture negative per report in rehab paperwork, remaining bacterial stool studies cancelled. on admission, was continued on po vancomycin. after worsening abdominal symptoms, he was started on iv flagyl as well. remained c. diff negative throughout admission. the flagyl was stopped but we elected to continue the po vancomycin for the duration of the ceftazidine course. 4. seizure disorder. developed post-cva per daughter. continued phenobarbital during admission. 5. chf. most recent echocardiogram in our system is from , with preserved systolic function and lvef of 75%. 6. hypervolemia - mr. is ~10l positive for his hospital admission, diuresing as tolerated with iv lasix. on day of discharge, he was recieving lasix 40 mg iv bid with plans to diurese 2l in 24h period. he should continue to be diuresed with iv lasix as tolerated. medications on admission: - albuterol/ipratropium inhaler 8 puff q6h - chlorhexidine 5 ml tid swish & spit - nystatin 5 ml swish & spit - phenobarbital 240 mg g-tube qhs - tamsulosin 0.4 mg po qhs - vancomycin 125 mg po qid - acetaminophen 650 mg g-tube q6h for pain or fever - bisacodyl 5 mg po daily prn constipation - senna 8.6 mg po qhs prn constipation - bacitracin topical ointment apply daily discharge medications: 1. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours): continue for 2 weeks after completion of antibiotics. 2. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day): swish and spit. 3. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po at bedtime. 4. ceftazidime 2 gram recon soln sig: one (1) recon soln injection q12h (every 12 hours): last day . 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 6. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for sob/wheezing. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for consitpation. 8. colace 100 mg capsule sig: one (1) capsule po twice a day. 9. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: eight (8) puff inhalation q4h (every 4 hours). 10. phenobarbital 20 mg/5 ml elixir sig: sixty (60) ml po hs (at bedtime): (dose =240mg qhs). 11. furosemide 10 mg/ml solution sig: forty (40) mg injection discharge disposition: extended care facility: for the aged - macu discharge diagnosis: tracheobronchmalacia respiratory failure pneumonia proctitis/lower gi bleed atrial fibrillation with rapid ventricular response hypernatremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: you were admitted to the hospital after an elevtive procedure to place a new stent in your airway for treatment of tracheobronchomalacia. after the procedure you developed a pneumonia as well a low blood pressure. your stent was removed and you were given antibiotics and supportive therapy with iv fluids. you also developed a lower gi bleed (blood per rectum). surgery and gastroenterology evaluated you and ct scan of your abdomen showed proctitis (inflammation of the very distal bowel). you were treated empirically for c. diff infection. you improved without intervention. you are being discharged to a long term facility for further care since you require intermittant time on the ventilator (at night). weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please arrange to see your outpatient physicians once you are discharged from the hospital. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances other intubation of respiratory tract rigid proctosigmoidoscopy endoscopic removal of bronchial device(s) or substances central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified anemia, unspecified acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site unspecified septicemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified personal history of tobacco use depressive disorder, not elsewhere classified chronic kidney disease, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute and chronic respiratory failure alkalosis other late effects of cerebrovascular disease septic shock chronic systolic heart failure paralytic ileus pressure ulcer, lower back epilepsy, unspecified, without mention of intractable epilepsy hyperosmolality and/or hypernatremia ventilator associated pneumonia late effects of cerebrovascular disease, aphasia proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site leukocytosis, unspecified other specified disorders of rectum and anus gastrostomy status pseudomonas infection in conditions classified elsewhere and of unspecified site tracheostomy status other diseases of trachea and bronchus dependence on respirator, status arthropathy, unspecified, site unspecified pressure ulcer, unspecified stage personal history of methicillin resistant staphylococcus aureus muscle weakness (generalized) unspecified hemorrhoids without mention of complication urethral stricture, unspecified 

Answer: The patient is high likely exposed to