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: patient recorded as having no known allergies to drugs attending: chief complaint: cough major surgical or invasive procedure: intubation/extubation right ij placement and removal picc line placement history of present illness: this is a 78 f with hx of copd, previous hx of intubations, presented to osh () with several day history of cough productive of yellow sputum. she denies c/p, shortness of breath, fevers, chills. of note history was limited by pt being on bipap. on presentation to the she was found to be hypoxic to mid 70s, abg 7.28/71/55 (ventmask o2) --> 7.30/67/87 (on bipap 10/5) --> 7.29/72/77 (on bipap 14/5); cxr consistent with rml pneumonia. received levofloxacin, furosemide, methylprednisolone 60 mg and transfered to ed. . in ed, t 99.8, 91, 138/71. abg: 7.23/88/88. she had an episode of desaturation to 90% on 100% nrb. with nppv, o2 sats improved to 96%. received vancomycin, piperacillin-tazobactam, methylprednisolone 65 mg in the ed. . in the micu, patient reports no shortness of breath, and states she is feeling comfortable. her vitals were stable from the ed, and she was continued on bipap at 10/5. past medical history: 1. copd - multiple previous intubations (per report, patient is a difficult airway) 2. asthma 3. rheumatoid arthritis 4. cerebral aneurysm s/p repair after rupture in 5. hypothyroidism 6. l bka/r great and second toe amputations pvd 7. previous admission for bilateral pleural effusion 8. cad 9. s/p bilateral hip replacement 10. patient is known to be a difficult intubation 11. episode of afib during hospitalization/intubation in social history: lives at home with her husband in . she reports she has daily home aides. prior history of smoking (1ppd x 61 years, quit 3 years ago). no alcohol. she has 4 children, three daughters and one son. family history: nc physical exam: admission: vs-t 94.6, 91, 118/45, 28, 98% bipap 10/5 gen-elderly woman, wearing bipap mask, comfortable heent-ncat neck-jvd elevated, seen on expiratory phase of breathing lungs-crackles bilaterally one third, scattered wheezes, moderate air movement heart-rrr, difficult to auscultate secondary to pulmonary sounds abdom-soft, nt, +bs extre-left bka, right great and second toe amputations, dp, pt palp on left, warm to touch hands-extreme ulnar deviation and contractures/deformity c/w ra neuro-grossly intact pertinent results: 02:00pm blood wbc-6.7 rbc-5.36 hgb-14.6 hct-47.7 mcv-89 mch-27.2 mchc-30.6* rdw-14.3 plt ct-375 11:50pm blood wbc-7.3 rbc-4.93 hgb-13.5 hct-44.2 mcv-90 mch-27.4 mchc-30.5* rdw-14.3 plt ct-357 03:41am blood wbc-5.5 rbc-4.29 hgb-11.5* hct-38.5 mcv-90 mch-26.8* mchc-29.8* rdw-13.7 plt ct-267 02:57am blood wbc-6.1 rbc-4.29 hgb-11.4* hct-39.5 mcv-92 mch-26.4* mchc-28.7* rdw-13.7 plt ct-275 04:48am blood wbc-4.0 rbc-4.26 hgb-11.5* hct-38.4 mcv-90 mch-26.9* mchc-29.9* rdw-13.6 plt ct-231 06:13am blood wbc-7.3# rbc-4.89 hgb-13.4 hct-42.3 mcv-87 mch-27.4 mchc-31.6 rdw-14.1 plt ct-278 02:00pm blood neuts-89.6* lymphs-7.8* monos-1.8* eos-0.4 baso-0.4 04:41pm blood pt-15.6* ptt-28.5 inr(pt)-1.4* 11:50pm blood pt-15.5* ptt-27.4 inr(pt)-1.4* 02:57am blood pt-15.3* ptt-65.1* inr(pt)-1.4* 04:48am blood esr-2 02:00pm blood glucose-103 urean-28* creat-0.9 na-139 k-7.5* cl-95* hco3-34* angap-18 11:50pm blood glucose-191* urean-31* creat-0.9 na-144 k-5.5* cl-99 hco3-33* angap-18 03:41am blood glucose-114* urean-38* creat-0.6 na-145 k-4.7 cl-108 hco3-34* angap-8 02:57am blood glucose-117* urean-39* creat-0.5 na-147* k-4.5 cl-108 hco3-33* angap-11 04:48am blood glucose-132* urean-30* creat-0.4 na-147* k-3.8 cl-107 hco3-37* angap-7* 06:13am blood glucose-88 urean-15 creat-0.4 na-148* k-3.3 cl-103 hco3-39* angap-9 02:00pm blood ck(cpk)-115 11:50pm blood ck(cpk)-65 02:00pm blood ck-mb-4 ctropnt-<0.01 probnp-* 11:50pm blood ck-mb-notdone ctropnt-<0.01 11:50pm blood calcium-8.5 phos-6.1* mg-2.0 03:41am blood calcium-8.4 phos-3.8# mg-2.0 02:57am blood calcium-8.4 phos-4.0 mg-2.1 04:48am blood albumin-3.2* calcium-8.5 phos-3.3 mg-2.0 06:13am blood calcium-8.4 phos-3.1 mg-1.8 11:50pm blood tsh-0.28 03:41am blood tsh-0.44 04:48am blood crp-8.5* 02:07pm blood lactate-1.5 12:09am blood lactate-1.5 12:09am blood freeca-1.14 . urine culture (final ): <10,000 organisms/ml. . urine culture (final ): yeast. >100,000 organisms/ml.. 1:43 am bronchoalveolar lavage site: lower lobe lt. lower lobe. leaking spec. sputum collection per req. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~1000/ml oropharyngeal flora. staph aureus coag +. ~3000/ml. sensitivities performed on culture # 250-9111f isolates are considered potential pathogens in amounts >=10,000 cfu/ml. 1:40 am bronchoalveolar lavage site: lower lobe rt. lower lobe. leaking spec. sputum collection per req. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. 10,000-100,000 organisms/ml.. of two colonial morphologies. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. penicillin sensitivity available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | erythromycin---------- r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s . legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . single ap upright view of the chest: there is marked interstitial prominence noted bilaterally. no focal pulmonary opacities are evident. there is no pleural effusion or pneumothorax. the pulmonary artery trunk is markedly prominent indicating pulmonary hypertension which may be related to patient's underlying copd. there is mild cardiomegaly. there is no evidence of volume overload. there is flattening of bilateral hemidiaphragms with overexpansion of lungs consistent with known copd. both humeri appear hypoplastic. this may represent a congenital deformity or old fracture deformities. impression: no acute cardiopulmonary process. marked prominence of interstitial markings and hyperexpansion may relate to copd. . ct chest : impression: 1. findings consistent with emphysema with superimposed interstitial edema. these findings in combination with respiratory motion limit assessment for coexisting chronic interstitial lung disease. a dedicated outpatient hrct when the patient can tolerate such a study would be helpful to further evaluate for possible interstitial lung disease, if clinical suspicion persists. 2. left basilar subsegmental atelectasis and trace bilateral pleural effusions. 3. evidence of pulmonary arterial hypertension. 4. left nonobstructing nephrolithiasis. small low-attenuation lesion in the left kidney, too small to characterize by ct. 5. diffuse coronary artery calcifications and atherosclerotic calcification within the aorta. 6. compression fracture within the mid thoracic spine of uncertain chronicity. . echo: conclusions the left atrium is elongated. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. there is moderate global left ventricular hypokinesis (lvef = 30-40 %). there is no ventricular septal defect. the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with significantly depressed free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate to severe tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is no pericardial effusion. . brief hospital course: a/p: this is a 78 year old female with history significant for severe copd, ra, hypothyroidism and pvd who presents with hypercarbic respiratory failure likely copd flare with ?rml pna now called out from micu to medicine floor and doing well. . # acute on chronic hypercarbic respiratory failure: pt's abg on admission was consistent with acute on chronic resp failure and patient subsequently decompensated requiring intubation (pco2 106) on . she was intubated, central line placed, and a bronchoscopy was done with results as described below. this was likely a copd exacerbation (based on cxr and history, p pulmonale seen on ekg, also pt admitted for copd flares in the past). restrictive processes may also be contributing, especially given her hx ra; these could include intrinsic parenchymal diseases vs. musculoskeletal pathology. also per report, had evidence of rml pna on osh film. as she described cough productive of sputum, she was treated with a 14 day course for a community aquired pneumonia exacerbating her copd. she was treated with ceftriaxone and azithromycin as she did not have rfs for mdr organisms (lives at home). a picc line was placed for outpatient iv antibiotic completion. she was also started on iv steroids which were subsequently slowly tapered. her bal results showed mssa; however, she was clinically improving on ceftriaxone and azithromycin so nafcillin was not added to her antimicrobial regimen. the patient self-extubated and continued to improve throughout her stay. she was transferred out of the icu to the general medicine floor and did well. she was continued on albuterol and ipratropium nebulizer treatments and satted at her baseline (88-92% on 2l nc). . # acute on chronic systolic and diastolic heart failure: probnp almost 20,000 on admission, no priors for comparison but markedly elevated. patient did receive lasix while in the icu, but appeared dry on arrival to the floor. echo was performed which showed lv hypertrophy and global lv hypokinesis, rv dilatation, and severe tricuspid regurgitation. also showed ef of 30-40%. patient was started on lisinopril and toprol for heart failure management which she tolerated well. she did not require any additional lasix for the duration of her stay. . # hypernatremia: patient developed several days of hypernatremia likely due to poor free water intake as she had been recently extubated and was taking minimal po given restricted use of her hands due to ra (patient is fed by her husband at home). free water po was encouraged. she received 2l d5w repletion over 2 days to replete her free water deficit, with improvement in her sodium. free water should be encouraged as patient requires 1:1 help with po due to very limited use of her hands. . # alkalosis: bicarb trended up since discharge from the micu, though has been relatively stable between 37 and 40. patient has chronic copd and may have been blowing off excessive co2 while on bipap and intubated. also was on higher nasal canula for first few days on the floor leading to increased retention (respiratory acidosis) with resulting metabolic alkalosis. basline co2 retention is unclear. based on vbg obtained, appears to be a chronic process (7.46 with pco2 of 58). also may have been small component of contraction alkalosis as the patient has limited use of her hands and has not had ready access to free water at all times. she has continued to appear clinically well and has oxygen saturations near her baseline of 88-92% on 2l nc. given her chronic copd, oxygen saturations above this should be avoided. . # a-fib with rvr: has history of this once in during critical illness/icu stay at , was not treated with rate control or anticoagulation. here, evening of went into a flutter in the setting of abg, and with iv dilt went into a-fib with rvr. has been in sinus since that time. she was not anticoagulated at this time given history of cerebral aneurysm rupture s/p clipping. patient also has only only developed atrial fibrillation at the time of infection and intubation. the patient's pcp was who felt that she is not likely good candidate for anti-coagulation given follow up as well. her tsh was within normal limits during admission and no structural abnormalities were noted on echo. she was started on a low dose beta blocker as above for her heart failure which will also serve as rate control. the issue of anticoagulation should be readdressed in the outpatient setting. . # ra: pt has severe ra based on physical exam, unclear if she takes dmards. patient states she has been on medication in the past which did not improve her symptoms, so she is not interested in further management. . # pvd: pt required bka secondary to non-healing ulcers. now has stage 4 pressure ulcer on left ischium that probes to bone per wound care nurse as well as wound on the gluteal cleft. ischial ulcer concerning for osteo. no wbc or fevers at this time. esr is 2. crp slightly elevated at 8. per patient's vascular surgeon, dr. , patient was treated conservatively with aggressive wound management from to with resultant healing of ulcer. apparently wound probed to bone at that time but did not have evidence of inflammation. wound currently has well-demarkated borders with no skin inflammation or exudate. aggressive wound care management was pursued during her hospitalization and should be continued. she was started on zinc, vitamins a and c and multivitamin with minerals to enhance wound healing. she should follow with her primary care physician and surgeon for further management. . # positive ua: initially in the setting of epis, likely contaminated, culture with 10,000-100,000 yeast. ua was rechecked with significant wbc/rbcs, positive le, neg nitrites, few bact and mod yeast with culture growing yeast; however, this was in the setting of foley still in place. ua was rechecked once foley was removed, and urinalysis did not show evidence of nitrite/le or yeast. culture was negative as well. no further management was needed. . # compression fracture: noted on ct scan, patient was not aware of this. does not report any recent falls. is wheel-chair bound and non-weight bearing at baseline. denies any back pain at this time. patient would not likely be a good candidate for kyphoplasty or vertebroplasty as she is asymptomatic. per the patient's new pcp, if the patient has had a recent bmd. she has been on and off prednisone for copd flares frequently over the last few years as well. she was started on calcium/vit d supplementations during her admission. bisphosphonate therapy can be considered as an outpatient. . # hypothyroid: continued on outpatient levothyroxine. tsh was within normal limits. . # fen: patient was evaluated by s&s. she was cleared for thin liquids, ground diet given no dentures and can have soft solids if dentures are in. . # access: l brachial picc in place which should be removed on completion of her antibiotics. . # code: full . -contact-son -pcp, () -vascular surgeon, dr. () medications on admission: omeprazole acetaminophen levoxyl 200 mcg daily discharge medications: 1. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 5. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 6. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. azithromycin 250 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 5 days. 9. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 10. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 11. prednisone 20 mg tablet sig: two (2) tablet po daily (daily) for 3 doses: start on . 12. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 4 doses: start on . 13. prednisone 10 mg tablet sig: one (1) tablet po daily (daily) for 4 doses: start on . 14. prednisone 5 mg tablet sig: one (1) tablet po daily (daily) for 4 doses: start on . 15. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 16. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 17. ceftriaxone-dextrose (iso-osm) 1 gram/50 ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 5 doses. 18. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 19. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily) for 8 days. 20. vitamin a 10,000 unit capsule sig: two (2) capsule po daily (daily) for 8 days. 21. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 22. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion: should not be given with synthroid. 23. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush: per lumen. 24. vitamin c 500 mg tablet sig: one (1) tablet po twice a day for 8 days. 25. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed). discharge disposition: extended care facility: hospital discharge diagnosis: copd exacerbation secondary diagnoses: atrial fibrillation in the setting of critical illness hypernatremia rheumatoid arthritis peripheral vascular disease hypothyroidism discharge condition: hemodynamically stable, oxygen saturation at baseline on home oxygen requirement discharge instructions: you had an exacerbation of your copd while you were here which required intubation. you were extubated and have done well since that time. you were also found to have a pneumonia and you are being treated with antibiotics for your infection. in addition, you had atrial fibrillation for a short time that resolved. you are not currently being treated for atrial fibrillation, but this can be followed by your primary care physician. you were found to have some heart failure while you were here. you were started on two medications for this: lisinopril and metoprolol. please continue to take these as directed. if you develop increased shortness of breath, fatigue, chest pain, weakness or any other concerning symptoms, please call your primary care doctor or go to the emergency room immediately. followup instructions: please follow up with your primary care physician, . within 2 weeks. you can call to arrange that appointment. you should also arrange an appointment with dr. to follow your sacral wound. you can call to arrange that appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnostic ultrasound of heart insertion of endotracheal tube closed [endoscopic] biopsy of bronchus diagnoses: pneumonia, organism unspecified other primary cardiomyopathies coronary atherosclerosis of native coronary artery congestive heart failure, unspecified unspecified acquired hypothyroidism atrial fibrillation peripheral vascular disease, unspecified personal history of tobacco use atrial flutter acute and chronic respiratory failure osteoporosis, unspecified pressure ulcer, other site rheumatoid arthritis chronic obstructive asthma with (acute) exacerbation hyperosmolality and/or hypernatremia diseases of tricuspid valve below knee amputation status other toe(s) amputation status hip joint replacement mixed acid-base balance disorder acute on chronic combined systolic and diastolic heart failure pathologic fracture of vertebrae chronic ulcer of other specified sites body mass index between 19-24, adult great toe amputation status dermatophytosis of other specified sites 

Answer: The patient is high likely exposed to