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: valium attending: chief complaint: hypotension, hypoxia major surgical or invasive procedure: trach change , , . in place at time of discharge. bronchoscopy history of present illness: yo from rehab with h/o htn, osteoperosis, and chronic resp failure to parkinson's disease, trached and peged d/t multiple aspiration events brought to the ed from his nh with concern for ams. he had an unresponsive episode last night, was reportedly hypoxic (unclear degree). staff at nh were also concerned about possible facial droop. the wife rescinded the dnr order prior to arrival and stated he is to be full code. ems suctioned a golf ball sized mucous plug from his trach. he has had episodes of mucus plugging in the past. recent hospitalization for hip fracture and ileus. urine culture from grew resistant ecoli. he was started on a 7 day course of ceftriaxone on . other micro history: urine w esbl kleb, resistant ecoli, pseudomonas resistant to zosyn in sputum and vre swab. . ed course: admission vitals at 0620 53 120/50 15 100. code stroke called with concern for new facial droop. ct head wo contrast was negative for acute intracranial hemorrhage. once family arrived they confirmed that facial droop was old. pt was documented dnr but was reversed for transport. family also clarified that code status is no compressions, but would want epinephrine and similar drugs. started ceftriaxone 1g for presumed uti. briefly hypotensive to 80's at 7am, got 1l ivf. vitals prior to transfer: 121/53, 55, 13, 100% on vent (fio2 40%, tidal volume 500, peep 5, rr 13). access: 20g hand, 22g hand, 18 r forearm. foley catheter from rehab not exchanged. . on the floor, pt c/o l hip pain. past medical history: 1. h/o aspiration pna - tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p placement on - pt continues to feed for pleasure at hebreb 3. parkinson disease 4. osteoporosis 5. t11/12 compression fx 6. lle osteomyelelitis as a child/chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. lue rotator cuff tear 9. prostate cancer s/p orchiectomy in 10. s/p laminectomy l4-5 11. cataracts s/p surgery . glaucoma 13. hypertension 14. h/o of treatment for pseudomonas and aspiration pna at heb reb 15. s/p trach with night ventilator support. 16. s/p wrist fx 17. chronic constipation 18. chronic abd pain- per heb reb notes 19. recent admission following vasovagal event at heb/reb s/p chest compressions complicated by ptx s/p chest tube 20. l ant pubic rami fracture, l ant iliac fracture social history: the patient has a sixty-pack-year history of tobacco. he quit in . he lives at rehab macu for last 3 hrs. he is a retired history professor. , no alcohol intake. - tobacco: none currently - alcohol: none currently - illicits: none family history: non-contributory physical exam: admission physical exam: vitals: t: 97.5 bp: 104/45 p:75 r:14 o2: 100% (fio2 40%, tidal volume 500, peep 5) general: alert, elderly male, trach on vent, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, trach site intact, no lad lungs: diffuse wheezes and rhonchi to auscultation cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, site intact skin: diffuse nonpitting edema dependent areas, stage 1 skin breakdown gu: foley in place ext: cool, well perfused, 2+ pulses, pitting edema to mid calves, no clubbing or cyanosis . discharge physical exam: general: alert, elderly male, trach on vent, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, trach site intact, no lad lungs: diffuse wheezes and rhonchi to auscultation cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, site intact skin: general anasarca gu: foley in place ext: cool, well perfused, 2+ pulses, pitting edema to mid calves, no clubbing or cyanosis . pertinent results: at admission: 06:25am blood wbc-14.1* rbc-3.37* hgb-9.4* hct-28.1* mcv-83 mch-27.8 mchc-33.4 rdw-17.9* plt ct-357 06:25am blood neuts-84* bands-2 lymphs-6* monos-3 eos-2 baso-0 atyps-0 metas-2* myelos-1* 06:25am blood pt-12.5 ptt-24.4 inr(pt)-1.1 06:25am blood glucose-122* urean-27* creat-0.9 na-128* k-6.1* cl-91* hco3-28 angap-15 03:18am blood albumin-2.8* calcium-7.9* phos-3.4 mg-2.3 12:43pm blood caltibc-220* vitb12-448 folate-greater th ferritn-96 trf-169* 06:25am blood osmolal-279 09:23am blood tobra-7.4 06:25am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 07:01pm blood type-art rates-/14 tidal v-450 peep-5 fio2-40 po2-121* pco2-50* ph-7.39 caltco2-31* base xs-4 intubat-intubated vent-controlled 06:25am urine color-yellow appear-hazy sp -1.006 06:25am urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-lg 06:25am urine rbc-4* wbc-174* bacteri-mod yeast-none epi-<1 transe-<1 05:00pm urine hours-random urean-52 creat-3 na-146 k-4 cl-140 06:25am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg micro: blood culture negative x2 sputum culture: 4:51 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): sparse growth commensal respiratory flora. pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing performed by . doripenem susceptibility testing requested by dr., . doripenem>32mcg/ml non-susceptible. mic interpretations are based on manufacturer's guidelines that are fda approved sensitivity testing performed by etest. pseudomonas aeruginosa. sparse growth. second morphology. piperacillin/tazobactam sensitivity testing performed by . amikacin and doripenem susceptibility testing requested by dr., . doripenem >32mcg/ml non-susceptible. mic interpretations are based on manufacturer's guidelines that are fda approved sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | amikacin-------------- =>64 r 16 s cefepime-------------- 16 i 8 s ceftazidime----------- 8 s 16 i ciprofloxacin--------- 2 i =>4 r gentamicin------------ =>16 r 8 i meropenem------------- 4 s 8 i piperacillin/tazo----- s r tobramycin------------ 8 i 2 s c.dif negative x3 , 22, 23 bronchoalveolar lavage: 3:58 pm bronchoalveolar lavage **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~3000/ml commensal respiratory flora. yeast. ~1000/ml. isolates are considered potential pathogens in amounts >=10,000 cfu/ml. gram negative rod(s). ~1000/ml. further workup on request only. isolates are considered potential pathogens in amounts >=10,000 cfu/ml. urine cx: 6:37 pm urine source: catheter. **final report ** urine culture (final ): gram positive coccus(cocci). ~4000/ml. sputum cx: 3:45 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): commensal respiratory 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. pseudomonas aeruginosa. sparse growth. sensitivities performed on culture # 330-8016c, . gram negative rod(s). rare growth. radiology: ct head noncontrast: impression: no acute intracranial hemorrhage or mass effect. if concern for acute infarct is high, please note that mr is more sensitive if not contra-indicated. total opacification of the right mastoid air cells, middle ear cavity and mucosal thickening in the right ethmoid air cells and maxillary sinus. cxr: 1. low lung volumes with bibasilar opacities which are stable and could reflect atelectasis vs pneumonia. 2. apparent inferior dislocation of the left humeral head, unchanged - please correlate clinicaly. cxr: tracheostomy tube is unchanged in position. left-sided picc follows a normal course terminating in the upper svc. a rounded opacity at the right base is somewhat less apparent on the exam; however, there is increased right-sided effusion and atelectasis. left basilar atelectasis and small effusion are also present. cardiomediastinal silhouette is stable. there is atherosclerotic calcification of the aortic arch. prominent mediastinal and hilar densities are compatible with calcified adenopathy. tte : poor image quality.there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets are moderately thickened. the study is inadequate to exclude significant aortic valve stenosis. mild (1+) aortic regurgitation is seen. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , no definite change (the rv appears similar). ct abdomen/pelvis with contrast: impression: 1. bilateral pleural effusions. 2. small right lower lobe infiltrate. 3. tube in place in the pylorus of the stomach. 4. no evidence of colitis. 5. scattered diverticula without evidence of diverticulitis. 6. normal-appearing appendix. 7. anasarca. 8. stable left iliac, left pubic rami, and bilateral inferior rami fractures. cxr : following right thoracentesis, there is no visible pneumothorax. small residual right pleural effusion is evident. previously reported pulmonary edema has nearly resolved. left lower lobe opacity and adjacent pleural effusion appears slightly improved. otherwise no relevant changes. the study and the report were reviewed by the staff radiologist. brief hospital course: y m hx of htn, osteoperosis, and chronic resp failure to aspiration from parkinson's disease, trach/ d/t multiple aspiration events s/p unresponsive episode at nursing home, ?hypoxia, mucus plugging and hypotension, and concern for left facial droop. 1. hypotension: patient initially presented with leukocytosis and bandemia. initially was placed on broad spectrum antibiotics with vancomyin, tobramycin, and cefepime. he was aggressively fluid resuscitated prior to arrival with >5lns. received picc line . urine, blood, and sputum were aggressively cultured. cxr failed to show striking infiltrate, though ventilator associated pnuemonia was suspected. his bp continued to trend to the 70s-80s, and so was started on dopamine drip on with appropriate bp response. sputum cultures from eventually revealed two distinct, resistant pseudomonas species, prompting an antibiotic shift to zosyn/tobramycin on . he underwent bronchoscopy and bal on . vancomycin was discontinued at that time. weaning his pressors proved to be extremely difficult, and therefore alternative explanations to his hypotension were sought. adrenal insufficiency was ruled out with a normal am cortisol of 14 and a normal cosyntropin stimulation test. midodrine was started for any possible autonomic dysfunction given his advanced parkinsons disease. he was started on levothyroxine 50mcg daily due to a low free t4 at 0.79. dopamine was changed to levophed on . he underwent abd/pelvis ct on for abdominal pain, which failed to reveal an infectious source. tamsulosin was discontinued due to concern that it affected his bp control. fluorinef was briefly used, though eventually discontinued as he was grossly fluid overloaded without sifnicitant hemodynamic effect. levophed was stopped on and his systolic blood pressure has since ranged from 110s-140s. he will continue a 14d antibiotic course for vap, with tobramycin ending and zosyn ending . 2. facial droop: felt to be non-stroke and confirmed baseline by his family. ct head negative in the ed and neuro did not feel that pt was having a stroke. 3. ventilator associated pneumonia: he was persistently hypoxic on admission. most concerning is ongoing mucus plugging but generally tolerated his home vent settings. chest xray poorly penetrated but possibly suggested rll infiltrate. noted to have high volume of secretions concerning for evolving pna. he was continued on home combivent inh and acetylcysteine for mucolytic.it was decided to treat for a 14d vap course on zosyn/tobramycin when 2 resistant pseudomonas species grew in his sputum. he received vancomycin for approximately 6 days which was stopped after culture data failed to reveal gram positive isolates. he was oxygenating well and tolerating short periods of time on tracheostomy mask by the time of discharge, and remained on his home vent settings. 4. altered mental status: resolved. likely uti vs pna vs hypoxia or other underlying infectious etiology. rescinded code stroke after family confirmed appearance baseline. some ams may have been due to narcotic overtreatment of his recent hip fractures, as his mental status seemed to improve with more conservative dosing. 5. uti: history of resistant ecoli and esbl org in past. started on broad abx per above. foley catheter was exchanged (arrived with condom cath from nursing home). urine cultures failed to reveal pathogenic levels of bacteria. 6. hyponatremia: initial hyponatremia to 128 eventually resolved with volume resuscitation, likely was due to hypovolemia. 7. pelvic fractures: prior admission, pt had new nondisplaced fracture involving left superior and inferior pubic rami w known left iliac fracture. pain control was continued with tramadol, oxycodone, tylenol, lidocaine patch, and ice. hip x-ray without acute fracture. 8.tracheostomy: patient chronically trached with occasional time off the vent. high trach pressures concerning. per wife, pt often spends 12-5pm off trach (sat 92% on mask) when he is well. he was continued on home combivent inh and acetylcysteine for mucolytic. he was bronched on and et tube was exchanged for larger size at that point. a noticeable cuff- continued, and his trach was again upgraded to a 9.0 on , however substantial cuff pressures were needed to prevent leakage. a tracheostomy tube was then placed on with improvement of his . 9. parkinson's disease: chronic. patient with severe dysphagia and tracheostomy. he continued home carbidopa/levidopa, entacapone, pramipexole. 10.macular degeneration: cont home eye gtt w warm compresses following. 11. fluid overload: patient roughly 8l positive fluid balance due to aggresive fluid resuscitation, hypotension, and multiple iv meds. he will require diuresis back down to his dry weight in his nursing home. 12. code status: wife clarified that code status is no compressions, but would want epinephrine and similar drugs. 13. anemia: his hct trended down from admission 28 to 21-22. received one prbc transfusion. iron, b12, folate wnl. hapto 282, retic: 2.1, ldh: wnl pending tests at discharge: -blood cultures (no growth to date) transitional care issues: - continue zosyn 4.5mg q6hr through - continue tobramycin 240mg q36hr through (last dose , needs one dose on only) - diuresis down to dry weight - check tsh and free t4 in 6 weeks - trend periodic hct for anemia - dvt prophylaxis with sc heparin due to inactivity - trend electrolytes and cr with diuresis medications on admission: *holding lasix 1. bisacodyl 10 mg suppository qam 2. carbidopa-levodopa 25-100 mg tablet : five (5) tablet po see comment (): po 7 times daily: 05, 08, 11, 14, 17, 20, 23. 3. lactulose 10 gram/15 ml solution : fifteen (15) ml po tid (3 times a day). 4. dorzolamide-timolol 2-0.5 % drops : one (1) drop ophthalmic (2 times a day): to both eyes. 5. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime): both eyes. 6. pramipexole 0.125 mg tablet : one (1) tablet po four times a day: at 0500, 0800, 1100, 1400. 7. pramipexole 0.5 mg tablet : one (1) tablet po qpm (once a day (in the evening)). 8. entacapone 200 mg tablet : one (1) tablet po see below (): seven times daily: 05, 08, 11, 14, 17, 20, 23 9. tamsulosin 0.4 mg capsule, ext release 24 hr : one (1) capsule, ext release 24 hr po hs (at bedtime). 10. lorazepam 0.5 mg tablet q4hours 11. ipratropium-albuterol 18-103 mcg/actuation aerosol : four (4) puff inhalation twice a day. 12. docusate sodium 50 mg/5 ml liquid : ten (10) ml po bid (2 times a day): (take 100 mg ) . 13. calcium carbonate 200 mg calcium (500 mg) tablet, chewable : one (1) tablet, chewable po tid (3 times a day). 14. cholecalciferol (vitamin d3) 400 unit qday 15. erythromycin ethylsuccinate 200 mg/5 ml suspension for reconstitution : 10ml q6hours 16. polyethylene glycol 3350 17 gram/dose powder : one (1) po daily (daily). 17. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 18. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback : one (1) intravenous q24h (every 24 hours) for 6 days. 19. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po bid (2 times a day). 20. fluticasone 50 mcg/actuation spray, suspension : one (1) nasal twice a day. 21. racepinephrine 2.25 % solution for nebulization : 0.5 ml inhalation q 2 hrs prn as needed for shortness of breath or wheezing. 22. omeprazole 40 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 23. ascorbic acid 500 mg capsule, extended release : one (1) capsule, extended release po once a day. 24. chlorhexidine gluconate 0.12 % mouthwash : one hundred-fifteen (115) ml mucous membrane four times a day: swish and spit . 25. acetaminophen 650 mg/20.3 ml solution : one (1) po tid (3 times a day) as needed for fever or pain. 26. oxycodone 5 mg tablet : one (1) tablet po q4h (every 4 hours) as needed for pain. 27. morphine 5 mg/ml solution : five (5) mg injection every four (4) hours as needed for pain: use for breakthough pain or if unable to take by g-tube. 28. acetylcysteine 100 mg intratracheal 29. gentamicin nebulizer 80 mg discharge medications: 1. bisacodyl 10 mg suppository : one (1) rectal once a day as needed for constipation. 2. carbidopa-levodopa 25-100 mg tablet : five (5) tablet po 7x daily (): 05, 08, 11, 14, 17, 20, 23. 3. dorzolamide-timolol 2-0.5 % drops : one (1) ophthalmic twice a day: to both eyes. 4. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime). 5. pramipexole 0.125 mg tablet : one (1) tablet po qid (4 times a day): 05, 08, 11, 14. 6. pramipexole 0.5 mg tablet : one (1) tablet po qhs (once a day (at bedtime)). 7. entacapone 200 mg tablet : one (1) tablet po 7 times daily (): 05, 08, 11, 14, 17, 20, 23. 8. lorazepam 0.5 mg tablet : one (1) tablet po q4h (every 4 hours) as needed for anxiety. 9. ipratropium-albuterol 18-103 mcg/actuation aerosol : two (2) puff inhalation q6h (every 6 hours) as needed for sob, wheeze. 10. calcium carbonate 200 mg calcium (500 mg) tablet, chewable : one (1) tablet, chewable po three times a day. 11. cholecalciferol (vitamin d3) 400 unit tablet : one (1) tablet po once a day. 12. erythromycin ethylsuccinate 200 mg/5 ml suspension for reconstitution : ten (10) ml po q6h (every 6 hours). 13. polyethylene glycol 3350 17 gram/dose powder : one (1) po once a day. 14. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : two (2) adhesive patch, medicated topical daily (daily) as needed for l hip, back. 15. omeprazole 40 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 16. ascorbic acid 500 mg tablet : one (1) tablet po once a day. 17. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane every six (6) hours. 18. acetaminophen 650 mg/20.3 ml solution : one (1) po three times a day as needed for fever or pain. 19. levothyroxine 50 mcg tablet : one (1) tablet po daily (daily). 20. midodrine 5 mg tablet : two (2) tablet po tid (3 times a day). 21. piperacillin-tazobactam 4.5 g iv q8h ***infuse over 3 hours*** 22. tobramycin 240 mg iv q36h 23. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 24. calcitonin (salmon) 200 unit/actuation spray, non-aerosol : one (1) nasal qhs (once a day (at bedtime)): alteranting nostrils. 25. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 26. lasix 40 mg tablet : one (1) tablet po once a day. 27. outpatient lab work please check cbc, sodium, potassium, chloride, bicarb, bun, creatinine, mag, phosp twice weekly to monitor chronic anemia as well as renal function while on diuretics 28. outpatient lab work please just thyroid function test in 6weeks to determine if levothyroxine dose needs to be adjusted discharge disposition: extended care facility: rehab discharge diagnosis: primary: pneumonia hypotension hypothyroid discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr it was a pleasure taking care of you. you were brought to for evaluation of altered mental status. head imaging was negative for stroke. while in house you developed hypotension as well as difficulty weaning of ventilation. . imaging and labs were concerning for potential pneumonia and you were started on broad spectrum antibiotics. with treatment of pneumonia your breathing improved. in addition we switched your trach with improvement in symptoms. . to treat your hypotension you were started on midodrine and treated for infection. . medications changes: to treat infection: 1. take tobramycin 240mg iv every 36hrs. your last dose of tobramycin at occurred on ; your last dose will be due on the 29th. 3. take zosyn 4.5mg every 6hrs. your last dose of antibiotics will be on . . to treat low blood pressure: 1. take midodrine 10mg. take one capsult three times daily . to treat hypothyroid 1. take levothyroxine 50mcg daily. ** you will need repeat tfts in 6weeks with plan for dose alteration if needed. . to prevent clot formation you were start on sq heparin. . again it was a pleasure taking care of you. please contact with any questions or concerns followup instructions: please follow-up with pcp 1 week procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances revision of tracheostomy replacement of tracheostomy tube replacement of tracheostomy tube replacement of tracheostomy tube diagnoses: anemia, unspecified urinary tract infection, site not specified unspecified essential hypertension hyposmolality and/or hyponatremia unspecified acquired hypothyroidism personal history of malignant neoplasm of prostate paralysis agitans 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 hypotension, unspecified osteoporosis, unspecified macular degeneration (senile), unspecified do not resuscitate status ventilator associated pneumonia pseudomonas infection in conditions classified elsewhere and of unspecified site other diseases of trachea and bronchus dependence on respirator, status attention to tracheostomy inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation facial weakness other fluid overload foreign body in trachea surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation unspecified orthopedic aftercare 

Answer: The patient is high likely exposed to