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: ace inhibitors attending: chief complaint: dizziness major surgical or invasive procedure: central line placement and removal. picc line placement echocardiogram history of present illness: mrs. is an 81 yo f with pmh dm2 on metformin, asthma, recent admission for cap/asthma exacerbation and new onset afib sent home on coumadin and diltiazem who presented to the emergency department complaining of dizziness. her hr was noted to be 50 upon presentation. she was diaphoretic and complaining of n/v. she reported that she took one extra er diltiazem today out of confusion. she was just started on this medication. she denies f/c, abd pain, diarrhea/constipation, chest pain, headache, confusion. she reports worse sob, orthopnea. she denies any other changes other than coumadin, diltiazem. . in the ed, vs were 106/42, hr 50, af. she received 4mg calcium gluconate, 2mg atropine as well as zofran, reglan, and compazine for n/v. she was put on an insulin drip and peripheral dopa for chronotropy. her lactate was noted to be over 10. she was given vanc and cefepime. her gas was 7.24/34/90 and she had new renal failure at 2.1 (bl 1.1). renal saw her in the ed as did tox. before transfer to the micu, her hr had improved to 85, bp 114/32, and she was satting 100% on 3l. she received 3l ns. . of note she was recently admitted from - for cap and asthma exacerbation. she failed outpatient tx with azithromycin and was changed to levaquin, for which she finished a 6 day course on . . on the floor her only complaint is sob. her hr is in the 80s. her sbp is in the 110s, though her map is < 60. past medical history: 1. asthma 2. t2dm 3. htn 4. hyperlipidemia 5. depression 6. osteoarthritis . pshx: 1. hip replacement 2. cataract surgery 3. appendectomy 4. hernia repair social history: lives alone but gets help for meals. husband has been in for 2 yrs and she frequently visits and feels caregiver . she has three sons. she denies smoking (remote history), alcohol or drug use family history: father died at age 57 of chf mother died at age 49 of cerebral bleed sister is eight yrs younger and has no known med problems physical exam: vitals: 93f hr 86 rr31 92% on 6l gen: moderately tachypneic, o/w comfortable, resting, cooperative heent: ncat, mmd, surgical pupils neck: no elevated jvp pulm: slight expiratory wheeze, o/w ctab cv: hrrr, no m/r/g abd: s/nt/nd/nabs, no hsm extr: 2+ pulses, warm, no c/c/e neuro: aox4, cn 2-12 intact grossly pertinent results: labs on admission: wbc 16.5 n 83.6, l 14.4, m 1.7 no bands hct 27.6 plt 592 inr 3.1 pt 30.4 ptt 29.2 alt 61 ast 82 ap 72 lip 43 tbili 0.5 na 134 k 5.6 cl 94 bicarb 13 bun 48 cr 2.1 glu 251 trop 0.02 ck 33 mb not done gas: 7.24/34/90 15 lactate 10.3 --> 7.3 ua neg for infection . blood culture, routine (final ): this is a corrected report at 3:25pm. reported by phone to at 3:25pm. corynebacterium species (diphtheroids). final sensitivities. erythromycin > 4 mcg/ml. sensitivity testing performed by sensititre. previously reported as. sensitive to erythromycin penicillin and vancomycin ( at 1:29pm). sent to labs for speciation per dr. .. refer to sendout system for results. sensitivities: mic expressed in mcg/ml _________________________________________________________ corynebacterium species (diphtheroids) | erythromycin---------- r penicillin g---------- 8 r vancomycin------------ <=1 s aerobic bottle gram stain (final ): gram positive rod(s). reported by phone to pat kins on at 0824. . cdifficile toxin - negative x 3 separate specimens. . studies: cxr : findings: there has been minimal improved aeration of the right lung base with persistent opacity noted. there is a more linear opacity noted in the lateral aspects of the right mid lung near an area of remote chronic healed rib fractures which may represent scarring. the previously noted mild volume overload has somewhat subsided to near resolution. there is mild tortuosity of the thoracic aorta. the cardiac silhouette is within normal limits for size accounting for patient and technical factors. the right costophrenic angle is again blunted, possibly due to a small pleural effusion. no left effusion is seen. there is no underlying pneumothorax. impression: relative to the most recent prior exam, there is an improved aeration of the right lung base with persistent opacity, possibly reflecting a resolving pneumonia with a small parapneumonic effusion. . renal u/s : impression: no evidence of hydronephrosis in either the right or left kidney . ecg: sinus rhythm. compared to the previous tracing of there is no significant change. . echo : the left atrium is moderately dilated. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. no vegetation seen (cannot definitively exclude). compared with the prior study (images reviewed) of , mitral regurgitation appears slightly more prominent brief hospital course: mrs. is an 81 yo f with pmh of asthma, dm2, htn, recent admission for pna treated with levaquin x6 days, presenting with bradycardia, hypotension, lactic acidosis and acute renal failure. . 1) bradycardia: based on her report of taking extra long acting diltiazem, her bradycardia and hypotension likely diltiazem overdose. in addition, she was in acute renal failure on admission which also likely contributed to ccb toxicity. she was evaluated by toxicology consult in the ed who agreed with this assessment. she was started on insuling gtt for ccb toxicity and started on dopamine gtt for hemodynamic support. she was admitted to the icu and her heart rate and blood pressure improved by the morning after admission and her insulin and dopamine were able to be weaned off in less than 24 hours. all nodal agents were held for the first 24 hours after which she was titrated up on metoprolol (to 100mg po bid) and diltiazem 240 mg sr (her home dose) for hr control. 2)lactic acidosis: she had a lactic acidosis on admission which resolved with ivf most likely to metformin in the setting of acute on chronic renal failure. her metformin was discontinued and will not be restarted on discharge given the lactic acidosis. 3)hypotension/bp control: she was initially on dopamine gtt due to hypotension thought most likely due to both diltiazem toxicity and sepsis given that she also had an elevated wbc count and was hypothermic on admission. she was covered broadly on admission to the icu to cover for partially treated nosocomial pneumonia with vancomycin and zosyn, beginning on . hypotension resolved the morning after admission once her hr recoverd and she was weaned off the dopamine gtt with no further hypotensive episodes. she later became hypertensive and her medications were re-started. final regimen included diltiazem sr 240mg daily, metoprolol 100mg po bid, and nifedipine cr 30mg daily. of note, her home regimen was diltiazem sr 240mg daily, atenolol 100mg and nifedipine 60mg daily. she can be changed over to her home regimen at rehab. infections will be discussed below. 4) infectious disease: as noted in hpi, she was undergoing treatment for community acquired pneumonia (r lung base) as an outpatient. in the hospital, she had significant leukocytosis which increased from 16 to 32 on the second day of admission as well as blood cultures from admission positive for corynebacterium species (diphtheroids). cxr showed persistent rll opacity, which may represent unresolved or recurrent pneumonia. as noted above, due to her hypotension and concern for sepsis, she was started on broad spectrum antibiotics (vanco/zosyn) from day 1. later flagyl was added for concern for cdifficile, but discontinued when 3 stools returned negative for cdiff toxin. she improved from a respiratory standpoint (weaned off oxygen, cough improved), and remained afebrile. id was consulted for assistance in management of the diphtheroids in the blood and ? diphtheria pneumonia. she was placed on droplet precautions for ? diptheria pneumonia, and the patient transitioned to oral penicillin only on hospital day #6. however, later same day (hospital day #6), the sensitivities on the corynebacterium returned indicating the bacteria was resistent to penicillin and sensitive only to vancomycin. therefore vancomycin was restarted at a renally adjusted dose. a trough was checked on and was low at 12.7. her vancomycin was increased to 750mg iv q12h. she will need to complete a total of 14 days, from . she should have a trough drawn after her third dose, on before the morning dose. a nasopharyngeal swab for diptheria culture and blood sent for diptheria antibody testing, but these are still pending at time of discharge. a picc line was placed on for administration of antibiotics. a trans-thoracic echo was done on and was negative for vegetation. surveillance blood cultures could be checked in the outpatient setting after she is off antibiotics. 5) resp distress: this was noted in the icu, and resolved by the time she was transferred to the medical floor. it was felt likely due to a combination of known copd, pneumonia, as well as volume overload after she received large amounts of ivfs for resuscitation. she was given iv lasix, standing nebulizers, and antibiotics as above. oxygen was weaned off. her requirement for nebulizers resolved. antibiotics were continued as above to complete a 14 day course. 6) renal failure: this was felt likely to ischemic atn while bradycardic and hypotensive. resolved with fluid resuscitation and treatment of infection. 7) paroxysmal afib: this was diagnosed at her prior admission. echo was done and unremarkable (see results). she initially had her rate-controlling agents held as she was bradycardic. later these were restarted, and titrated up to current doses (home dose diltiazem sr 240mg, along with metoprolol 100mg -). she was continued on coumadin and will be dishcarged on 5mg daily. an inr should be repeated in days. 8) dm: she was an insulin drip and d10 in the icu for treatment of ccb toxicity per toxicology service. metformin was held throughout hospital stay b/c of lactic acidosis. she was placed on glipizide 5mg after being called out to floor, which was uptitrated to 10mg due to elevated blood sugars. she was also covered with an insulin sliding scale. final diabetic regimen deferred to outpatient setting. 9) anemia - her hct decreaed in the icu, as low as 23. it then stabilized and improved to 25 and remained stable x several days. iron studies revealed iron 25, ferritin 206, caltibc 302 trf 232, vit-b12 1088, folate 15.1, most consistent with anemia of acute inflammation. she did have guaiac positive brown stools but no sign of acute gi bleeding. she will need an outpatient colonoscopy. 10) fen: cardiac/diabetic reg diet, replete lytes prn 11) ppx: she was on stress ulcer prophylaxis while in icu (ranitidine), but this was discontinued on the medical floor. she was maintained on sc heparin and a bowel regimen. 12) code: full medications on admission: meds (per d/c summary ): 1. fluticasone-salmeterol 250-50 2. citalopram 10 mg daily 3. nifedipine 60 mg sustained release daily 4. atenolol 100 mg daily 5. ferrous sulfate 325 mg qday for 2 months. 6. glipizide 5 mg 7. warfarin 5 mg 8. metformin 1000mg 9. aspirin 81 mg 10. atorvastatin 20 mg 11. calcium carbonate 1000 mg 12. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours) prn 13. diltiazem hcl 240 mg sustained release qday 14. vitamin d-3 400 unit . discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 6. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 8. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed. 11. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 12. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. insulin lispro 100 unit/ml solution sig: as directed units subcutaneous asdir (as directed): per sliding scale. 14. warfarin 5 mg tablet sig: one (1) tablet po daily (daily): check inr in days. 15. glyburide 5 mg tablet sig: two (2) tablet po bid (2 times a day). 16. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 17. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 18. calcium carbonate 500 mg capsule sig: one (1) capsule po tid (3 times a day). 19. vitamin d 400 unit capsule sig: two (2) capsule po once a day. 20. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 21. vancomycin 750 mg iv q 12h duration: 7 hours dose 1: , end on to complete a 14 day course discharge disposition: extended care facility: rehab of discharge diagnosis: 1. acute renal failure 2. septic shock 3. pneumonia 4. bradycardia, likely medication effect 5. anemia, likely acute inflammation 6. acute metabolic acidosis, likely due to lactic acidosis. discharge condition: afebrile, on room air. heart rate and blood pressure controlled. discharge instructions: you were admitted with low blood pressure, slow heart rate, and infection (pneumonia and bacteria in your blood). you were in the intensive care unit and also had renal failure, likely due to your blood pressure and poor perfusion of the kidney. fortunately, the blood pressure, heart rate, and kidney failure have all resolved. your pneumonia was treated and you will continue antibiotics for the blood infection up to . your medications were changed as follows: 1. stop atenolol. take metoprolol 100mg twice a day instead. your doctor at rehab or your primary care doctor may elect to switch you back to atenolol at a later date 2. your dose of nifedipine is less, currently at 30mg daily (you were taking 60 mg daily at home). again, this may be changed back to your home dose by your rehab physician 3. continue your warfarin at 5mg daily. please have your inr checked in 3 days 4. you will be on vancomycin until , 750mg iv q12 hours. you will need to have a trough checked at rehab after 3 doses. 5. you should stop metformin due to a complication called lactic acidosis. do not take this again until you speak to your outpatient doctor 6. your glipizide dose was increased to 10mg . you also are given insulin coverage for now, but may not need this as an outpatient. . you will need an outpatient colonoscopy b/c you had low blood count without evidence of overt bleeding. your stool had microscopic amount of blood in it. . you had an echocardiogram to rule out infection on your heart valve, and this was negative. your primary care doctor may order surveillance blood cultures after you complete your antibiotics. . call your doctor if you have fever, chills, feel dizzy, have chest pain, or any other symptoms. followup instructions: provider: , md phone: date/time: 10:15 provider: . phone: date/time: 11:15 provider: , orthopedic private practice phone: date/time: 11:15 md, procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: pneumonia, organism unspecified acidosis other iatrogenic hypotension anemia in chronic kidney disease acute kidney failure with lesion of tubular necrosis diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation depressive disorder, not elsewhere classified chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure other specified cardiac dysrhythmias insulins and antidiabetic agents causing adverse effects in therapeutic use other specified septicemias septic shock chronic obstructive asthma, unspecified coronary vasodilators causing adverse effects in therapeutic use other specified diphtheria 

Answer: The patient is high likely exposed to