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) attending: chief complaint: increased sob major surgical or invasive procedure: tracheal intubation mechanical ventilation chest tube placement x 2 arterial cannulation central venous cannulation bronchoscopy tracheostomy peg tube placement pleurodesis history of present illness: 85 year old woman admitted with a chief complaint of hypoxia. she was admitted to after 10 day hospitalization at for left below the knee amputation. she has a history of steroid use for oxygen dependent copd. on arrival at , her o2 sat was 97% on 2l. she has had a steadily increasing oxygen requirement since, progressing to the point on the day of admission of being on bipap 14/8 15l. when her mask is removed for even a few seconds, she desaturates to the low 70s. she has been evaluated for her hypoxia by various coverage physicians over the weekend and was treated with nebulizer treatments and lasix with little improvement. she also had a cxr on which showed a left lower lobe pneumonia for which she is on ceftriaxone, flagyl, and vancomycin. on the day of admission, she was tachypneic, more hypoxic, with decreased responsiveness, and was sent in for evaluation. on exam in the ed, she was noted to have decreased air movement with rhonchi and faint wheezes which improved with nebulizer treatments. her cxr was not impressive. an ekg showed multifocal atrial tachycardia and mild lateral st depressions. she was initially placed on bipap in the ed; after nebulizer treatments, she improved and was put back on nasal cannula. she then again got worse in the ed, and an abg was 7.25/94/66. the patient was thus intubated in the ed for worsening respiratory failure and sent to the . past medical history: type 2 diabetes hypertension gout osteoporosis chronic obstructive pulmonary disease, steroid dependent, oxygen-dependent, (fvc 1.89,fev1 0.83, fev1/fvc 44, dlco: severely reduced) paroxysmal atrial fibrillation anemia peripheral neuropathy secondary to diabetes gastroesophageal reflux disease history of mrsa hyperthyroidism past surgical history: right below knee popliteal bypass graft with nonreversed saphenous vein and a left popliteal bypass graft with saphenous vein angiogram on . mastectomy in . picc line placement . left bka social history: the patient is a resident at rehabilitation. there is no smoking or alcohol history. family history: noncontributory physical exam: t 100.8 hr 106 bp 163/69 o2sat 90% ac tv 400 x 20 peep 5 fio2 0.5 gen: patient intubated, responsive and sedated heent: perrl, sclera anicteric, op with ulcers, mmm lungs: diffuse tubular sounds ant/lat cardiac: irregularly irregular no murmurs abdomen: soft nt nabs ext: left bka, surgical wound intact, staples in place; right le no edema, black necrotic right big toe. right dp +2 at ankle neuro: sedated pertinent results: admission labs: cbc: wbc-21.1*# rbc-3.64* hgb-10.2* hct-33.3* mcv-91 mch-27.9 mchc-30.6* rdw-17.9* plt ct-646* diff: blood neuts-81.8* lymphs-13.3* monos-3.5 eos-0.8 baso-0.6 coags: pt-13.3 ptt-37.1* inr(pt)-1.2 chem 10: glucose-86 urean-28* creat-1.0 na-147* k-4.2 cl-103 hco3-38* calcium-7.9* phos-2.6* mg-2.0 abg: type-art temp-37.0 rates-40/ fio2-50 po2-66* pco2-94* ph-7.25* calhco3-43* base xs-9 intubat-not intuba comment-ventimask other: lactate-1.1 cardiac enzymes: ck(cpk)-14* ck-mb-notdone ctropnt-0.06* -> ck(cpk)-14* ck-mb-1 ctropnt-0.04* thyroid tests: tsh-0.10* free t4-0.7* t4-3.3* discharge labs: imaging: admission cxr: 1. worsening of right upper lobe opacity near the future, which are somewhat linear. although it could represent subsegmental atelectasis, cannot rule out the presence of pneumonia. 2. background emphysema and pulmonary fibrosis as well as pulmonary artery hypertension. 3. bilateral small pleural effusions are stable. admission cta chest: 1. no evidence of central pulmonary embolism. 2. right lower lobe consolidation/atelectasis; this likely represents pneumonia in the correct clinical setting. 3. stable mediastinal lymphadenopathy, most prominent in the ap window and precarinal distribution. 4. severe fibrotic, bronchiectatic, and cystic changes consistent with the known history of copd. no pneumothorax as was demonstrated on the prior ct. 5. several smaller focal areas of consolidation bilaterally, the most prominent of which in the left lower lobe, just superior and anterior to the dominant area of consolidation. while these may represent multifocal areas of infection or fibrotic change, followup should be obtained to exclude malignancy. 6. small left-sided pleural effusion. 7. mild prominence of the central main pulmonary artery, likely consistent with the given history of pulmonary arterial hypertension. head ct : there is no evidence for hemorrhage. the ventricles, sulci, and cisterns demonstrate no effacement. the white matter junction is preserved. there are multiple hypodensities seen in the subcortical and deep white matter as well as both thalami that are the sequelae of chronic small arterial ischemia. there is a frothy fluid within both maxillary sinuses, sphenoid sinuses, and right mastoid air cells that may indicate sinusitis. the osseous structures are unremarkable. cxr : very large left-sided pneumothorax with signs of tension. chest ct : findings: the large left hydropneumothorax, mostly air filled was also shown on plain chest radiographs earlier today. since it shifts the mediastinum rightward and everts the left hemidiaphragm, it may be causing hemodynamic tension as well. the left lung is tethered to the chest cage by many pleural adhesions. right lower lobe consolidation is improving and edema has resolved. emphysema is severe. a 6- cm bulla marginates the left major fissure and smaller bullae are seen elsewhere . the airways are patent up to the segmental bronchi. there is no right pleural or any pericardial effusion. subcentimeter mediastinal nodes not meet ct size criteria for lymphadenopathy. extensive atherosclerotic coronary artery calcifications are noted, along with substantial aortic valvular calcification. there is no pericardial effusion. in the upper abdomen, the imaged liver, spleen, adrenals, and kidneys are unremarkable. a 24-mm gallstone is noted without evidence of cholecystitis. there are no suspicious bone findings. et tube and ng tube are in good position with the ng tube terminating in the body of the stomach and the et tube well above the carina. impression: 1. large left hydropneumothorax could be under tension and hemodynamically significant. 2. severe emphysema including a 6 cm bulla along the left major fissure. 3. improving right lower lobe consolidation. 4. decreasing pulmonary edema. cxr pm: compared with the examination obtained approximately 6 1/2 hours earlier, a left chest tube has been inserted, with its tip ending in the apex. the left pneumothorax has markedly diminished and is now small, best seen at the left lateral costophrenic angle. the mediastinum is now midline. the endotracheal tube is in satisfactory position. a nasogastric tube descends into the abdomen. there is a background of chronic lung disease and emphysema. scattered nonspecific opacities are present bilaterally. cxr : left lung appears to be completely re-expanded. the left apical pleural tube is relatively short intrathoracic and the tip of the basal tube is not its entire course is extrathoracic. little if any left pleural effusion or pleural air. mild pulmonary edema is unchanged. heart size is normal, although larger than it was prior to chest tube insertion. tip of the et tube is in standard placement and a nasogastric tube passes into the stomach and out of view. dr. was paged to discuss these findings at the time of dictation. cxr : one of the two left basal pleural tubes have been withdrawn approximately 6 cm now projecting over the cardiac apex and left hemidiaphragm. the other tube is unchanged in position, tip just to the left of the midline at the level of the left hemidiaphragm. no appreciable left pneumothorax. small left pleural effusion may have increased. small right pleural effusion unchanged. subcutaneous emphysema in the chest wall and neck is still severe but improving. heart size remains top normal. heterogeneous opacification in the lungs is probably a combination of pulmonary edema, multifocal pneumonia and emphysema. tracheostomy tube in standard placement. gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. yeast. sparse growth. enterobacter cloacae. rare growth. identification and sensitivities performed on culture # 203-0763r . staph aureus coag +. rare growth. sensitivities performed on culture # 203-1121r . brief hospital course: assessment: 85yo woman with chronic obstructive pulmonary disease, admitted with respiratory failure, intubated in the ed, likely secondary to multilobar pneumonia, chronic obstructive pulmonary disease, and congestive heart failure, complicated by a pneumothorax. hospital course is discussed below by problem: 1. respiratory failure - her initial respiratory failure was thought to be multifactorial, secondary to multilobar pneumonia, chronic obstructive pulmonary disease with very poor baseline function, and congestive heart failure. she was treated with vancomycin, zosyn, and azithromycin for 14 days for broad coverage given that she had recently been living in health care facilities. dfa for influenza and urinary legionella antigen were both negative. sputum cultures only grew yeast, which was thought to be contamination. most recent sputum cultures grew e coli, thought to be a contaminant as well, as the patient has been afebrile, with resolving leukocytosis, unremarkable chest x-ray, and no other symptoms of a pneumonia. she then developed a low grade temperature and with 2/16 sputum culutres with 2+ gnr and with a history of enterobacter, she was restarted on a 10 day course of meropenem to be finished at rehabilitation. her sputum culture grew gram positive cocci and she was started on a course vancomycin, to complete a 10 day course of vancomycin and 10 day course of meropenem. her vancomycin had been supratherapeutic and was being monitored daily for dosing purposes. she was day fo vancomycin on , she still remained supratherapeutic on day of discharge at 31 (on day ). her chronic obstructive pulmonary disease was treated with albuterol and atrovent, though she was not very responsive to these medications. she was also given a dose of solumedrol 125mg iv, with a subsequent prednisone taper that was ongoing at the time of discharge. she was diuresed intermittently throughout the hospitalization (see below) she was intubated in the emergency room and had a tracheostomy on . her ventilator weaning was complicated by a cuff leak, requiring 30mmhg pressure to seal. this improved, and she has done well on pressure control. she has also had several trach collar trials, during which she tires within 10-15 minutes. 2. pneumothorax - on the morning of , the patient's chest x-ray showed a vertical linear opacity consistent with pneumothorax. a chest ct at the time confirmed a large pneumothorax involving most of her left lung. this was thought to occur secondary to positive pressure with preexisting severe bullous disease, and likely occurred the night prior to the chest x-ray, as she began to have low blood pressure responding to iv fluids that night. thoracic surgery was called, and in concert with interventional pulmonology, they placed a chest tube in the apex of the left lung. she was determined to still have an element of pneumothorax at her left lung base, so a second chest tube was placed. the apical chest tube was displaced slightly and caused subcutaneous emphysema, but it was effective and was able to be clamped and removed on without complications. the basilar chest tube manifested an inspiratory leak which resolved until the patient's tracheostomy, at which time the leak recurred. as such, the thoracic team performed pleurodesis x 3 () with doxycycline. the chest tube was set to suction and the inspiratory leak resolved. the chest tube was clamped and removed without complications. a chest x-ray after chest tube removal showed no pneumothorax. however, that night she became increasingly tachypneic, and a cxr in the morning showed recurrence of the pneumothorax. another chest tube was placed, with a significant amount of resulting subcutaneous emphysema (head to toe) and no significant change in the pneumothorax. a second chest tube was thus placed, which resulted in some improvement in the pneumothorax. her course was also complicated by a bronchopleural fistula, requiring pressure control ventilation. her fistula gradually resolved, and she has been able to be adequately supported on pressure control ventilation. since that time, her subcutaneous emphysema has gradually improved. her chest tubes were put to water-seal on , then were clamped on , and daily cxrs have revealed no evidence of recurrent ptx. the chest tubes were sequentially clamped and then removed with serial chest xrays revealing no pneumothorax. the pt is to follow up with thoracics surgeon dr. after discharge. 3. hypotension - she had an episode of hypotension in the setting of her pneumothorax. initially, it responded to fluid boluses and, given that the patient had been aggressively diuresed previously, was thought to be secondary to hypovolemia. this was likely just a contributing factor to hypotension caused by pneumothorax. it resolved after chest tube placement. once she was normotensive, her metoprolol was restarted. 4. fluid status - on admission, the patient was volume overloaded. she responded well to lasix 40mg iv. this was held in the setting of hypotension (with her pneumothorax), and was thought to be hypovolemic at that time. she has been intermittently volume overloaded, with good response to lasix. over the past 4 days prior to discharge the pt was euvolemic, not requiring any lasix. 5. mental status - early in the hospitalization, the patient was noted to have decreasing responsiveness. this was likely related to her sedation, as once the sedation was lessened, she became very appropriate and responsive. she also has had difficulty in regulating sleep/wake cycles. primary team has been moderately succesful in improving this with pm ambien, gabapentin, nortriptyline, and haldol. 6. yeast infection - she had urine cultures sent that showed only yeast, and vaginal discharge consistent with yeast. she was treated with one dose of fluconazole with resolution of her symptoms. 7. atrial tachycardia - she had a rhythm consistent with multifocal atrial tachycardia, most likely secondary to her underlying pulmonary issues. her metoprolol was restarted and the tachycardia resolved. 8. atrial fibrillation with rapid ventricular response - ms. has known paf, but she had increasingly frequent episodes of rvr to the 150s, with stable blood pressures. her metoprolol and diltiazem dosages were increased, with some effect, but she continued to have these episodes with maximal doses. she was placed on an esmolol drip, which helped ms. to revert to nsr at a dose of 100mcg/min, but experienced recurrent episodes on the drip. the electrophysiology service was consulted, who recommended started amiodarone. she was po loaded, and placed on 200mg po bid, in addition to her previous dose of diltiazem. her comorbid lung and thyroid conditions were noted in terms of managing with amiodarone, but this was thought to be the most appropriate treatment option. daily ekgs were obtained to assess for prolonged qt. the pt was switched from diltiazem to metoprolol as the pt has been noted to have better rate control with bb than ccb. the pts amiodarone was weaned down to 200 mg po qd prior to discharge. she developed episodes of atrial fibrillation while on amiodarone and cardiology was consulted and she was started on a low dose heparin drip for possible dccv if she became hypotensive. long term anticoagulation is to be determined as an outpatient the pt will need ekg's to assess for qt prolongation. her outpt pcp will also need to assess reinitiation of coumadin; pt seems to be a likely fall risk per nursing. her heparin gtt was discontinued on day of discharge. 9. diabetes - she was monitored with fingersticks. initially, she was treated with an insulin drip, but she was later switched to a sliding scale. her bs were generally well controlled. 10. urinary tract infection - urine culture grew e. coli and enterobacter clocae on . she was treated with a 7 day course of meropenem. 9. hypertension - other than during her brief episode of hypotension, she was treated with her outpatient metoprolol and diltiazem. the pts medications wer changed to metoprolol and amiodarone. 10. peripheral vascular disease - plavix and aspirin was continued. vascular surgery was consulted to assess her gangrenous toe, but the decision was made to defer any interventions until such time as her respiratory status had significantly improved. the pt is to follow up with vascular surgery 1 month after discharge to f/u her dry gangrene. she had no post-operative complications stemming from her recent left bka. 11. hyperthyroidism - she was continued on methimazole. her tsh was high and free t4 low. this needs to be readdressed as an outpatient, as her current status was likely complicated by her stay in the icu, and should be assessed once in an outpatient setting. nutrition - she was treated with tube feeds, initially by orogastric tube, then by peg once she had the tracheostomy. communication - her son, , lives in , and can usually be reached at . code status - full medications on admission: atrovent neb flagyl 500mg iv q8 ceftriaxone 1gm iv daily monistat derm lasix 40mg po q8 vancomycin 1gm iv daily fosomax 70mg q sat asa 325mg daily tapazole 5mg po daily lopressor 75mg q8 plavix 75mg daily cardizem 30mg po q8 colase 100mg 60mg daily nuerontin 100mg robitussin 200mg heparin sc riss mvi prednisone 2.5mg daily nortrptyline 25mg qhs zantac 150mg serevent 50 probenecid 500mg accolate 10mg daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. methimazole 5 mg tablet sig: one (1) tablet po daily (daily). 4. ipratropium bromide 18 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 5. zafirlukast 20 mg tablet sig: 0.5 tablet po daily (). 6. docusate sodium 150 mg/15 ml liquid sig: thirty (30) ml po bid (2 times a day) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. zantac 150 mg capsule sig: one (1) capsule po once a day. 9. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 10. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 11. insulin glargine 100 unit/ml solution sig: fifteen (15) units subcutaneous at bedtime. 12. insulin regular human 100 unit/ml solution sig: sliding scale units based on fs see attached sheet for details. injection four times a day. 13. multi-vitamin tablet sig: one (1) tablet po once a day. 14. fosamax 70 mg tablet sig: one (1) tablet po once a week: once weekly on sat. 15. 60 mg tablet sig: one (1) tablet po once a day. 16. nortriptyline 25 mg capsule sig: one (1) capsule po hs (at bedtime). 17. lorazepam 0.5-1 mg iv q6h:prn use before haldol for agitation 18. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 19. amiodarone 200 mg tablet sig: one (1) tablet po once a day. 20. morphine sulfate 1-4 mg iv q2h:prn 21. ferrous sulfate 300 mg/5 ml liquid sig: five (5) cc po daily (daily). 22. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 23. gabapentin 250 mg/5 ml solution sig: one hundred (100) mg po bid (2 times a day). 24. olanzapine 5 mg tablet sig: one (1) tablet po hs (at bedtime). 25. haloperidol 1 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. 26. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q1hr () as needed. 27. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 28. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 29. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for toe pain. 30. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po once a day. 31. meropenem 1 g recon soln sig: one (1) intravenous twice a day for 2 days. disp:*4 grams* refills:*0* 32. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po three times a day. disp:*135 tablet(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: primary: 1. pneumonia 2. copd with bullous disease on home oxygen 3. pneumothorax 4. atrial tachycardia 5. atrial fibrillation secondary: 1. dm ii 2. peripheral vascular disease with necrotic toes 3. hyperthyroidism 4. anemia 5. hypertension discharge condition: stable. discharge instructions: please follow up with all of your doctors, including your pcp as well as your vascular surgeon regarding your necrotic toes. please weight yourself daily, if you notice a significant increase in your weight more than 3lb daily, please call your pcp for possible change in medications. please note several changes have been made in your medication regimen. for details, see the following changes: 1. you should continue your antibiotics for the prescribed length of time. 2. please continue to take your aspirin, plavix, and lopressor as you have been doing. you are on a new medication called amiodarone. 3. your serevent has been discontinued as it would be difficult to take with the tracheostomy tube. instead place take albuterol ih 6 puffs q4 hours in addition to the atrovent ih 6 puffs q4 hours. 4. please continue your other medications as you have been doing as well. if you develop any chest pain, palpitations. shortness of breath, fevers, chills, nauseas, vomiting, diarrhea or other concerning health problems, please call your pcp or come directly to the ed. followup instructions: 1). please follow up with your pcp within two weeks of discharge. 2). please follow up with thoracics dr. 3). please follow up with dr. (vascular surgeon) on at 9:45 am, suite 5c, procedure: insertion of intercostal catheter for drainage insertion of intercostal catheter for drainage 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 non-invasive mechanical ventilation percutaneous [endoscopic] gastrostomy [peg] other intubation of respiratory tract temporary tracheostomy closed [endoscopic] biopsy of bronchus injection of antibiotic injection into thoracic cavity transfusion of packed cells diagnoses: pneumonia, organism unspecified urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm acute and chronic respiratory failure pneumonitis due to inhalation of food or vomitus iatrogenic pneumothorax long-term (current) use of insulin pressure ulcer, lower back emphysema (subcutaneous) (surgical) resulting from procedure hypovolemia atherosclerosis of native arteries of the extremities with gangrene below knee amputation status empyema with fistula emphysematous bleb candidiasis of vulva and vagina 

Answer: The patient is high likely exposed to