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: penicillins / sulfa (sulfonamides) attending: chief complaint: rapid heart rate major surgical or invasive procedure: cardioversion history of present illness: 60yo woman with past medical history significant for ventilator-dependent asthma/copd with tracheostomy, cad s/p mi, diabetes, chf w/ ef 25-30%, h/o multiple pneumonias including pseudomonas and transferred from for supraventricular tachycardia and found to be septic. she was recently admitted to () with respiratory distress, diagnosed with ventilator-associated pneumonia and sepsis with hypotension to 60s/40. while at , she was started on vancomycin, gentamycin, and cefepime; urine cultures were neg. sputum pos for klebsiella ( to amikacin, imipenum, zosyn) and pseudomonas (pseudomonas resist to cipro, levo, intermdi to gent). she was also treated with pressors which were slowly weaned prior to discharge on . she was transferred to hospital rehabilitation center on an antibiotics course of iv vancomycin, amikacin, and cefepime. she was sent to for svt with hr 130-160 beginning at 1020am. she was given cardizem 20+25mg and adenosine 6+12mg without confersion. she was also noted to have a fever of 103. on arrival to the ed, t104.6, hr 155, bp 140/75, rr 23/ sao2 98%. she was given tylenol 650mg, hydrocortisone 100mg iv, vancomycin (patient got cefepime and amikacin at rehab earlier in the day). adenosine 6mg ivp revealed underlying aflutter which reverted back to svt in the 150s. she was given an additional 20mg iv diltiazem, hr remained in 150s and bp dropped to 90s/50s. she was placed on a diltiazem drip. . on diltiazem drip patient rate remained in 150s, decision was made to cardiovert patient and she returned back to sinus rhythm. past medical history: 1. chronic respiratory failure, vent-dependent, weaned off the ventilator at in early but placed back on the ventilator at an unknown time. - h/o severe asthma and chronic hypercarbia w/ baseline pco2 in the 70s, on chronic steroids - s/p tracheostomy, last changed in and associated with trach malposition after that 2. cad s/p mi 3. chf, ef 25-30% 4. niddm 5. peripheral neuropathy 6. s/p 7. cri, baseline cr 1.5-2 8. schizoaffective d/o 9. steroid myopathy 10. ?bipolar d/o social history: living in the community in , hospitalized since. h/o tobacco. has a caseworker in the community from dept of mental health. large family. family history: noncontributory per report physical exam: vs: t 104.6, hr 157, bp 139/76, rr 24, sao2 99% cpap 5 fio2 0.5 tv 400 rr 25 (fio2 increased from 0.4 and now on cpap) gen: obese african american female who is awake but does not respond to commands. patient unkept. heent: perrl, uncooperative with eye exam. patient will not open her mouth. neck: no jvd appreciated. patient with left subclavian tlc cv: tachycardic, unable to tell if has murmur pulm: course breath sounds ant/lat b/l abd: obese, tube in place. foley in place. ext: + edema l>r with 2+ pitting edema in left, 1+ in right neuro: patient awake, otherwise not responsive or follows commands pertinent results: 01:05pm wbc-11.4* rbc-3.79* hgb-11.2* hct-35.1* mcv-93 mch-29.5 mchc-31.9 rdw-16.0* 01:05pm neuts-96.2* lymphs-2.7* monos-0.9* eos-0.1 basos-0 01:05pm plt count-317 01:05pm pt-13.5* ptt-29.8 inr(pt)-1.2 01:05pm d-dimer-* 01:05pm tsh-0.45 01:05pm glucose-337* urea n-42* creat-1.8* sodium-154* potassium-3.7 chloride-110* total co2-31 anion gap-17 01:18pm lactate-2.5* 01:25pm urine blood-lg nitrite-neg protein-neg glucose-250 ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 01:25pm urine rbc-* wbc-0-2 bacteria-occ yeast-none epi-<1 01:25pm urine color-straw appear-clear sp -1.009 12:00am alt(sgpt)-22 ast(sgot)-18 ld(ldh)-261* ck(cpk)-151* alk phos-62 amylase-80 tot bili-0.3 12:00am lipase-53 12:00am albumin-2.7* calcium-9.4 phosphate-2.9 magnesium-1.7 labs on discharge : 06:06am blood wbc-8.5 rbc-3.23* hgb-9.5* hct-28.9* mcv-90 mch-29.3 mchc-32.7 rdw-15.2 plt ct-238 06:06am blood plt ct-238 06:06am blood pt-15.6* ptt-74.7* inr(pt)-1.7 06:06am blood glucose-117* urean-48* creat-1.3* na-146* k-3.3 cl-103 hco3-38* angap-8 06:06am blood calcium-8.8 phos-3.2 mg-2.0 05:48am blood free t4-0.9* . micro: respiratory culture (preliminary): oropharyngeal flora absent. pseudomonas aeruginosa. heavy growth. of three colonial morphologies. . l subclavian cath tip culture (final ): due to mixed bacterial types ( >= 3 colony types) . urine culture (final ): no growth. brief hospital course: . ## asthma/ventilation dependence - patient after cardioversion required to be on assist control vantilation. a chest xray showed patchy opacities r>l and sputum culture was sent which was consistent with pseudomonas. patient was continued on amikacin and cefepime which she was already on before she was brought to . a total 14 day course of cefepime will be complete on and amikacin was extended for 7 more days and should be complete on . patient was conitnued on vancomycin for mrsa pna that she was already being treated for. her course of vancomycin was finished on . she quickly improved on the ventilator with good o2sat and was switched to pressure support of and and then tried on trach mask which she tolerated well. patient was evaluated for possible pm valve but it was noticed that she has air cuff and the pilot to the air cuff has been removed. not quite clear why pilot to air cuff removed or if it was torn off. patient has been doing fine with current tracheostomy so deferred any intervention of changing tracheostomy to facility who placed the trach to evaluate. please make sure patient trach changed if need be. . ## cardiac: 1) tachycardia - patient cardioverted and quickly returned to sinus rhythm with good rate and remained in sinus rhythm. patient was started on low dose bblocker which was not able to be titrated up given low hr and low bp. could try to titrate up bblocker if hr and bp tolerate. she was started on anticoagulation s/p cardioversion. she will need to be anticoagulated for total 3 weeks. on discharge patient on heparin gtt until inr theraputic at 2-3. would check daily inr and titrate coumadin until inr stable and therputic. can stop coumadin after 3 weeks. 2) chf - patient with reported ef of 30%. repeat cxr shows persistant r sided pulmonary opacity/effusion. restarted patient on lasix 40mg iv bid. can titrate up lasix up or down as tolerated and would keep patient even to slightly negative. can decrease lasix if blood pressure low. if patient blood pressure stable she should be started on acei as tolerated outpatient given her chronic renal insufficiency and diabetes. . ## fever - patient intially febrile when admitted. her fever curve improved while in hospital and wbc returned to . cxr shows b/l patchy infilitrate r>l which could represent aspiration pna. patient treated for klebsiella,mrsa/pseudomonas pna. sputum cx here shows pseudomonas. patient had left ij placed and left subclavian removed (tip grew back > 3 colonies of bacteria), which could have been source of fever. patient should complete antibiotic course as stated above. . ## hypotension - patient blood pressure running 90-100. on admission patient given hydrocortisone 100mg q8 as was on prednisone outpatient. tapered down to 75mg q8, and then switched to prednisone 40mg daily. would continue to 2 week prednisone taper to off or low dose if patient needs chronic steroids for copd. . ## diabetes - patient on 80am and 20pm nph and riss on admission. given patient gets continuous tube feeds changed nph to 60units am/pm and riss. can titrate nph up and down as needed. . ## hypernatremia - patient intially hypernatremic with na 154. she was given free water via iv and tube and switched to just free water via tube as her na corrected. would continue to monitor na and adjust free water flushed via as needed. . ## hypothyroidsim - patient found to have and borderline low tsh and low freet4 so was started on levothyroxine 50mcg. patient should have her thyroid function tests rechecked in 3 months. . ## chronic renal insufficiency - most likely diabetic nephropathy. patient at baseline 1.5-2. cre currently stable at 1.2 . ## psych - continued clozapine and valproic acid, and lexapro at current dose. valproic acid level 24 and clozaril level sent out. appreciate psych assistance. . ## tube - patient tube was noticed to be leaking. gi was contact and tube fixed. . ## access - patient left subclavian line was removed and noticed to have puss. a new left ij was placed. once patient off heparin gtt and iv antibiotics would consider removing central line. medications on admission: lasix 80mg lovenox 150mg sc qd x 10d beginning vancomycin 1000mg iv q48h, doses due , , amikacin 500mg iv q24h last dose 10/9 cefepime 2gm iv q12h 40mg qd (started , last dose 10/15) lactulose 30gm thiamine 100mg qd montelukast 10mg qpm atovaquone 1500mg q24h feso4 300mg tid clozapine 100mg qhs valproic acid 750mg qam and 500mg qhs simethicone 80mg simvastatin 20mg qhs mvi 15ml qd asa 81mg qd oscal +d qd glucerna at 55cc/hr ssi nph 80units at 6a, 20units at 6p lexapro 20mg qam protonix 40mg qd colace 100mg prednisone 40mg daily discharge medications: 1. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 2. montelukast 10 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 3. atovaquone 750 mg/5 ml suspension sig: one (1) po q 24h (every 24 hours). 4. clozapine 100 mg tablet sig: one (1) tablet po hs (at bedtime). 5. valproate sodium 250 mg/5 ml syrup sig: one (1) po qam (once a day (in the morning)). 6. valproate sodium 250 mg/5 ml syrup sig: one (1) po hs (at bedtime). 7. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day) as needed. 8. simvastatin 10 mg tablet sig: two (2) tablet po hs (at bedtime). 9. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 10. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 11. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 12. acetaminophen 160 mg/5 ml solution sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 13. ferrous sulfate 300 mg/5 ml liquid sig: one (1) po tid (3 times a day). 14. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 15. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 16. levothyroxine sodium 50 mcg tablet sig: one (1) tablet po daily (daily): please give at least 30 minutes separate from iron supplement. 17. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 18. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 19. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 20. prednisone 20 mg tablet sig: two (2) tablet po daily (daily). 21. amikacin 250 mg/ml solution sig: four hundred (400) mg injection q24h (every 24 hours) for 3 days. 22. furosemide 10 mg/ml solution sig: one (1) injection (2 times a day). 23. heparin (porcine) in d5w 100 unit/ml parenteral solution sig: one (1) intravenous asdir (as directed): please continue until inr theraputic . 24. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 25. cefepime 2 g piggyback sig: one (1) intravenous every twelve (12) hours for 3 days. 26. insulin nph human recomb 100 unit/ml suspension sig: sixty (60) units subcutaneous twice a day: please titrate as needed. discharge disposition: extended care facility: hospital discharge diagnosis: primary diagnosis: atrial flutter s/p cardioversion pseudomonas pneumonia hypernatremia central line infection secondary diagnosis: diabetes mellitus schizoaffective disorder/bipolar disorder asthma copd chronic renal insufficency chf discharge condition: stable - patient still on ventilator however appears to tolerate trach mask and should be on trach mask if tolerates. patient currently being treated for pseudomonas pna with amikacin and cefepime. discharge instructions: please continue to take medications as directed. while you were in the hospital you were treated for a fast heart rhythm. you were started on a medication called metoprolol which you should continue. you were also started on blood thinning medication which you should continue for total 3 weeks. you were also found to have a pneumonia which you are on antibiotics for and should continue. you were also found to have hypothyroidism and should continue to take thyroid medications (levothyroxine) as directed. y followup instructions: please follow up with your primary care doctors to over your medications. you will need to have your thyroid function tests rechecked in 3 months. you should also stay on anti-coagulation medication for 3 weeks and have blood levels checked to make sure on appropriate dose of coumadin. please follow up with your psychiatrist to go over your psychiatry medications and make sure they are appropriate. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances other electric countershock of heart diagnoses: nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere unspecified septicemia severe sepsis unspecified acquired hypothyroidism diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes atrial flutter chronic kidney disease, unspecified acute and chronic respiratory failure pneumonia due to pseudomonas pneumonitis due to inhalation of food or vomitus infection and inflammatory reaction due to other vascular device, implant, and graft chronic obstructive asthma, unspecified hyperosmolality and/or hypernatremia diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled pneumonia due to klebsiella pneumoniae gastrostomy status tracheostomy status schizoaffective disorder, unspecified 

Answer: The patient is high likely exposed to