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: metformin attending: chief complaint: cough, hypotension major surgical or invasive procedure: intubation, tracheostomy placement, peg placement history of present illness: history obtained from nurse supervisor at and patient's brother , hcp. . ms. is a 43 yo woman with a history cva, stage iv chronic kidney disease, dm, htn. she has received all of her prior care through and currently lives at nursing home since a cva in . her baseline status since that time has been bedbound but communacative. since approximately , her family has noted deteriorating ability to communicate. she is unable to talk but alert. for one week her nurse mental status including repeating that she flet like dying. on the morning of , she was at her recent baseline, alert, responsive, underwent hd at 11 am. at 5 pm she was noted to have an episode of yelling, followed by coughing. on exam she had increasingly rhonchorus breath sounds and increased cough and thought to be at risk for aspiration. no witnessed aspiration. she was also noted to be febrile to 101.8 and hypoxic to 87% on ra, bp 95/66 (baseline not recorded), rr 24. she was given oxygen by 2l nasal canula with an increase to 93% on ra. fs 153. her brother requested transfer to the hospital. . from , she was transferred to despite instructions from her brother to go to where she has received all of her previous care. in the . ed initial vital signs were bp 84/49, hr 110, t 101.8, rr 30, o2 sat 75% nrb. breath sounds were rhonchorus. she was given etomidate 20 mg iv and rocuronium 50 mg x 1 and easily intubated. she required no further intubation once sedated. she was also given vancomycin 1g, zosyn 4.5 g. sbp fell to 68 peri-intubation. levophed gtt was started with which sbp rose to the low 100s. 1l ns to 40 meq k at 200 cc/h was started. she was admitted to the icu for further management. past medical history: cva with residual l hemiparesis esrd on hd t/thurs/sat x years ( ) htn dm social history: from originally, emigrated to the us in the . lifetime nonsmoker, occasional etoh prior to decline during the past year. family history: no family history of renal disease or stroke physical exam: admission exam: vs: 110/66, hr 98, rr 23, o2 100% (vent settings 400/14, fio2 .6, peep 5) gen:intubated, sedated, not arousable skin: stage 2 coccygeal ulcer, b/l heel abrasions heent: intubated chest: diffusely rhonchorus l>r anteriorly. cardiac: regular rhythm; no murmurs, rubs, or gallops. abdomen: no apparent scars. non-distended, and soft without tenderness extremities: rue fistula with palpable thrill, r femoral catheter clean and dry, no peripheral edeme neurologic: intubated, sedated, not responsive to voice or painful stimuli. r pupil 4 mm and nonreactive, l pupil 3-->2 mm. pertinent results: admission labs: chemistry: 149/2.9/107/30/22/4.5<217 cbc: 19.4>8.9/29.2<397 (85% pmn, 11% lymphs) coags: 13.2/38.8/1.1 lactate 2.1 urine tox negative, ucg negative ua: wbc, rbc, negative nitrites, epis urine cx, blood cx pending . abg (intubated on 100% fio2) - 7.38 / 49 / 232 . echo: the left atrium is normal in size. no thrombus/mass is seen in the body of the left atrium. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. . mri brain: 1. evolving bihemispheric watershed infarcts without evidence for new infarct from the prior study. 2. sequelae of extensive chronic microvascular white matter ischemic disease throughout the supratentorial compartment and brainstem. 3. findings of retinal detachment with subretinal hematoma and/or proteinaceous fluid. 4. right mastoid air cell effusion. . cxr: in comparison with study of , the endotracheal tube has been removed and replaced with a tracheostomy tube. no evidence of complication. central catheter remains in place. nasogastric tube has been removed. there is some vague opacification at the left base that could represent a focus of consolidation. however, this is not much different from the prior study. overlying apparatus somewhat obscures detail. brief hospital course: 43 yo woman with hx esrd dm, cva, presents with fever, hypoxia, hypotension, and leukocytosis, most likely secondary to sepsis. . # possible sepsis: hypotension and leukocytosis were initially concerning for infection. source was never determined. cxr with possible rll infiltrate which could be consistent with her history of high risk for aspiration. sputum, blood, and urine cultures as well as c diff toxin were persistently negative. tte was negative for vegetation. she was initially given vancomycin and zosyn which was narrowed to vancomycin alone after culture data were negative. vancomycin was later stopped given lack of definitive evidence of infection, but wbc immediately rose and the patient became febrile. vancomycin was thus restarted and infectious work-up redone and was again negative. vancomycin was discontinued. . # respiratory failure: after hypotension resolved, patient easily passed spontaneous breathing trials while intubated. however, when extubated she developed excessive secretions and failed to hold her neck in a way that maintained adequate ventilation. thus, she repeatedly failure trials of extubation and required reintubation. this was discussed with her brother, and the decision was made to proceed with tracheostomy and peg placement. because of a large thyroid, this could not be done at the bedside but required a procedure in the or by thoracics on . her respiratory status remained stable for the remainder of her hospitalization. . # altered mental status: brother reported recently mental status for 3 months with an acute decline per nurse in the past few days culminating in event the day of admission. per nurse, patient has been quite depressed, raising the question of ingestion (? related to cxr findings), but tox screen here negative. later in her course, patient became more arousable and was following commands and communicating in one-word phrases. however, the day of planned discharge after tracheostomy, she was noted to be progressively less responsive and displaying repetitive grimacing movements. neurology was consulted. repeat mri showed no new stoke. eeg monitoring displayed seizures (see below). at time of discharge patient remains largely unresponsive (responds to painful stimuli only). neurology team followed patient throughout admission. the etiology for her altered mental status at time of discharge was not entirely clear. the decline likely represents continued damage in the setting of new seizures and subacute strokes. no clear metabolic or infectious cause of encephalopathy at time of discharge. . # seizure activity: newly discovered in micu, as above. neurology was following. she was given iv ativan, loaded with phenytoin and then, when seizures persisted, reloaded with fosphenytoin. standing keppra was started. seizures persisted. keppra dose was adjusted and seizure activity on eeg resolved. last documented seizure activity on . unfortunately, with resolution of seizures her mental status did not improve. recommend continuing current keppra regimen and following up with dr. in epilepsy clinic on monday at 10 am. to keep this appointment the patient's new "primary care physician" must call the clinic for a referral. . # vap: patient developed low grade fever, and increased sputum production on . she was started on empiric treatment for ventilatory associated pneumonia (vap). sputum cultures grew e. cloacae. with initiation of antibiotics she became afebrile and persistent leukocytosis started to decline. recommend completing a 14 day course of vancomycin (hd dosing) and meropenem (last dose on ). . # stage iv chronic kidney disease. undergoes hd at t/th/sat. got dialyzed today. no urgent electrolyte indication for dialysis on admission. fosrenal and nephrocaps were continued. thrice weekly dialysis was continued. she was frequently mildly hypotensive and tachycardic after dialysis but responded nicely to 250cc fluid boluses. . # dm: home dose of lantus and ss insulin were continued. she was initially hypoglycemic, so lantus was downtitrated. glucose stable on glargine 11 u qhs and sliding scale insulin. . # htn: metoprolol and lisinopril were held initially while requiring pressors. metoprolol was later restarted for mild hypertension and sinus tachycardia. just prior to discharge patient's blood pressure became elevated and her home lisinopril was restarted. . # hx cva: with residual r hemiparesis. mri on admission demonstrated subacute strokes. the stroke service recommended aspirin and plavix. these were started, but plavix was held for 1 week awaiting trach/peg. patient to continue aspirin and plavix indefinitely. . # nutrition: continue patient on tube feeds. due to some issues with residuals she was started on narcan and reglan to increased motility. due to some concern that these mediations may influence mental status these medications were discontinued and she was started on erythromycin for motility. currently doing well without residuals. would continue erythromycin for the next several days and then do a trial without erythromycin to insure gastric emptying. patient is dmt1 and will require adjustments in insulin regimen if feeds are changed. patient should also continue to receive multivitamins for micronutrient support as this could also be contributing to mental status dysfunction. . full code status was discussed with the patient's brother, . agreement to intubation was confirmed with patient the day she was extubated (and reintubated). family meeting was held again to readdress goals of care. because her neurologic prognosis cannot be determined in the acute setting of recent seizures and cva the decision was made to readdress goals of care (i.e. code status) in a few weeks when patient's mental status may be more indicative of prognosis. at time of discharge patient remained full code. medications on admission: metoprolol succinate 200 mg daily cymbalta 60 mg daily lidoderm patch x 12 hours daily lisinopril 30 mg daily asa 81 mg daily buspar 5 mg daily at 12 pm bactroban nasal oinment vitamin c 250 mg fosrenal 1000 mg tid humalog qac (can not read dose - 5 units) humalog ss lantus 24 units qhs tylenol 650 mg 30 minutes prior to dressing change ducolax 10 mg prn mom prn prn simvastatin 80 mg daily senna 8 mg daily omeprazole 20 mg colace 100 mg heparin sc tid reglan 10 mg qid nephrocaps qd vitamin d 50 000 iu qd heparin discharge medications: 1. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 4. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 5. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 6. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 7. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 9. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 10. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 11. erythromycin 250 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q6h (every 6 hours) for 3 days. 12. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. 13. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous hd protocol (hd protochol) for 8 days: last dose . 14. levetiracetam 100 mg/ml solution sig: five hundred (500) mg po bid (2 times a day). 15. levetiracetam 100 mg/ml solution sig: two y (250) mg po three times per week (): following dialysis. 16. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q24h (every 24 hours) for 8 days: give everyday (after hd on hd days). last dose . mg 17. insulin continue insulin regimen of glargine 11 units qhs and sliding scale humalog with meals. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagoses: sepsis (unknown etiology) respiratory failure ventilatory associated pneumonia seizures secondary diagnoses: subacute cvas ckd stage iv htn dm1 discharge condition: patient is nonverbal, responsive only to painful stimuli. she tolerates tube feeds. a tracheostomy is in place. respiratory status is stable on trach mask. discharge instructions: you presented to the hospital with low blood pressure and low oxygen levels concerning for a serious infection. you required intubation to help your breathing. unfortunately you were not unable to be extubated and you required a tracheostomy. your mental status was altered. neurology was consulted and you were found to be having seizures. you were started on seizure medications and your seizures resolved. you remained largely unresponsive. because of your inability to eat a feeding tube was surgically placed. you tolerated tube feeds well. during your admission you had a fever and increased sputum. sputum cultures grew a bacteria and you were treated with iv antibiotics. at the time of discharge you were no longer having fevers or increased sputum. your respiratory status was stable. you remained unresponsive. the prognosis of your mental status cannot be determined at this time. you will follow up with a neurologist to review your prognosis next month. followup instructions: please call once a primary care physician has been assigned at your rehab center to confirm your follow up appointment at clinic at for monday 10am with dr. . procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis arterial catheterization temporary tracheostomy other gastrostomy diagnoses: end stage renal disease renal dialysis status unspecified septicemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonitis due to inhalation of food or vomitus long-term (current) use of insulin septic shock pressure ulcer, lower back late effects of cerebrovascular disease, hemiplegia affecting unspecified side epilepsy, unspecified, without mention of intractable epilepsy encephalopathy, unspecified ventilator associated pneumonia diabetes mellitus without mention of complication, type i [juvenile type], not stated as uncontrolled cerebral artery occlusion, unspecified with cerebral infarction hypotension of hemodialysis pressure ulcer, stage iii retinal detachment with retinal defect, unspecified 

Answer: The patient is high likely exposed to