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 / clindamycin / celery / apple / bees attending: chief complaint: abnormal venous blood gas at rehab and joint pains and abdominal pain major surgical or invasive procedure: none history of present illness: 60f w/ hx of copd, pah w/ cor pulmonale, right-sided chf, ckd, s/p tracheostomy on in setting of copd exac and resp failure, who presents with left sided arm pain and question of abnormal vbg suggestive of hypercarbia at rehab. pt reports pain in her left wrist, left elbow, both feet. pain feels similar to a gout flair. also notes abdominal pain which is chronic since . her daughter reports that she has had increased secretions from her trach lately. pt has had several recent admission over the last few months. she had a recent admission from for shortness of breath thought initially to be pneumonia but eventually attributed to copd exacerbation as opposed to infection. due to respiratory failure she underwent a tracheostomy on . . recent admission for malfunctioning tracheostomy. at that admission, trach was replaced with tracheostomy piece. pt initialy on vent and then weaned off. found to be anemic, anemia of chronic disease, she was transfused 1 u prbc for hct 24. she also had advancement of dophoff per ir, nutrition adjusted tube feeds. . in the ed, initial vs were: t 98.2 hr 98 102/65, 26 99%, tm 101.5. vbg performed in ed did not show any signs of hypercarbia. bnp 5000 and cxr with pulm edema, given 20mg iv lasix. ct abd and pelvis was performed (pt was ventilated to allow her to lie flat) and is pending. pt refused leni on extremities. ua positive and started on levofloxacin 750mg iv, vanco 1g and cefepime 2g. pt found to have foul smelling yellow drainage around trach site, covered broadly with vanco/cefepime. after ct head, chest, abd, pelvis, she was transfered to the micu for close observation. . on arrival to the micu, pt is comfortable, on the vent. reports pain in hands and feet, similar to prior gout flairs. reports some abd pain. vitals: bp 108/55, hr 84, cmv fio2 30%, tv 400, peep 5, f18, satting 97%. past medical history: 1. morbid obesity (s/p gastric bypass) 2. obstructive sleep apnea (noctural bipap 18/15, home oxygen requirement of 3-4l via nasal cannula) 3. obesity hypoventilation syndrome 4. severe pulmonary artery hypertension (attributed to osa) 5. cor pulmonale (right heart failure attributed to severe pulmonary hypertension) 6. asthma 7. osteoarthritis (bilateral knee involvement) 8. diastolic heart failure (2d-echo showing lvef 70-80%, pap 64 mmhg) 9. chronic kidney disease (stage iii-iv, baseline creatinine 1.8-2.2) 10. rosacea 11. hypertension 12. iron deficiency anemia 11. s/p ventral hernia repair with mesh and component separation () 12. s/p gastric bypass surgery () 13. s/p debridement of anterior abdominal wall and complex repair () social history: coming in from rehab, she has 2 adult children, but adopted 3 so total of 5 children. she notes no toabcco use, rare alcohol use currently but notes a former heavy alcohol history in the distant past. she denies recreational substance use. family history: notable for diabetes mellitus in her mother and sister, hypertension in siblings, mother and throughout the maternal family as well as kidney disease. physical exam: admission exam vitals: vitals: bp 108/55, hr 84, cmv fio2 30%, tv 400, peep 5, f18, satting 97%. general: no acute distress, obese female, comfortable appearing, responds yes/no to questions, unable to talk bc trach in place, on vent. heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: anterior lung fields sound clear, no crackles. trach with some mild brown dried secretion around tube. gu: foley abd: mildly distended, some tenderness throughout to deep palpation, large midline scar from prior gastric bypass surgery ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. trace pedal edema joint: pain in joints of wrists, elbows, ankles. left wrist is warm, mildly red. discharge exam tcurrent: 36.5 ??????c (97.7 ??????f) hr: 83 (80 - 110) bpm bp: 94/59(66) {94/52(64) - 125/88(92)} mmhg rr: 19 (13 - 22) insp/min spo2: 96% general: no acute distress, obese female, comfortable appearing, responds yes/no to questions, unable to talk trach in place, on vent. heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: anterior lung fields sound clear, no crackles. gu: foley abd: mildly distended, some tenderness throughout to deep palpation, large midline scar from prior gastric bypass surgery ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. trace pedal edema joint: pain in joints improved. left wrist is warm pertinent results: admission labs 12:10am blood wbc-5.4 rbc-3.10* hgb-8.5* hct-28.6* mcv-92 mch-27.4 mchc-29.7* rdw-15.8* plt ct-305 12:10am blood neuts-74.0* lymphs-17.1* monos-6.8 eos-1.2 baso-0.8 12:10am blood glucose-154* urean-40* creat-1.1 na-150* k-3.6 cl-105 hco3-34* angap-15 12:10am blood alt-17 ast-15 ck(cpk)-31 alkphos-82 totbili-0.4 12:10am blood lipase-8 12:10am blood ctropnt-<0.01 probnp-5268* 12:10am blood albumin-2.7* 03:33pm blood phos-1.9* mg-2.1 uricacd-6.9* 12:16am blood type- po2-67* pco2-44 ph-7.51* caltco2-36* base xs-10 -assist/con 06:51am blood lactate-0.8 discharge labs 02:01am blood wbc-9.1 rbc-2.72* hgb-7.8* hct-24.8* mcv-91 mch-28.6 mchc-31.4 rdw-16.0* plt ct-309 02:01am blood plt ct-309 02:01am blood glucose-158* urean-45* creat-1.5* na-141 k-3.7 cl-95* hco3-35* angap-15 02:01am blood calcium-8.4 phos-3.5 mg-1.7 02:27am blood lactate-0.8 studies cxr cardiomegaly and pulmonary vascular congestion appears similar compared to most recent prior exam. no pleural effusion or pneumothorax is detected on this view. tracheostomy appears to be in standard position. right picc tip projects over the low right atrium. impression: 1. persistent cardiomegaly and pulmonary vascular congestion. 2. right picc terminating in the right atrium. this finding was reported to dr. by dr. by telephone at 6:02 a.m. on . ct chest/abd/pelvis 1. dilated loops of fluid-filled small bowel with decompressed distal ileum consistent with early or partial small bowel obstruction. the transition point is in the right lower quadrant and is likely due to adhesions. there is no bowel wall thickening, free fluid, or free air. 2. status post gastric bypass surgery with the nasogastric tube in the jejunum. 3. enlarged pulmonary artery consistent with patient's known pulmonary hypertension. 4. bibasilar atelectasis. no evidence of pneumonia. 5. tracheostomy in standard position. ct head 1. no evidence of acute intracranial process. 2. mucosal thickening of paranasal sinuses with aerosolized secretion in the sphenoidal sinuses, might represent acute sinusitis in the appropriate clinical setting. u/s distended gallbladder with small shadowing stones. the appearance of the gallbladder is indeterminate for cholecystitis by ultrasound. no specific signs are seen; however, the patient was noted to be tender at the site of the gallbladder on real-time imaging. consider a hida scan if further evaluation is needed of the gallbladder. wrist xr unchanged soft tissue swelling. no definite fractures. no dislocation. no definite erosions identified. no significant degenerative changes. unchanged alignment. impression: no significant interval change. cxr picc line has been withdrawn to the approximate level of the superior cavoatrial junction. lung volumes are low exaggerating mild vascular congestion which is improved, and moderate cardiomegaly and mediastinal venous engorgement which has not. no pleural effusion. tracheostomy tube in standard placement. feeding tube passes below the diaphragm and out of view. brief hospital course: 60f w/ hx of copd, pah w/ cor pulmonale, right-sided chf, ckd, s/p tracheostomy on in setting of copd exac and resp failure, who presents to ed with polyarthalgias, abdominal pain and question of abnormal vbg suggestive of hypercarbia at rehab although repeat vbg here consistent with baseline. . # polyarthritis: pt with pain in small joints of left hand and ankles, similar to prior gout flairs. pts most recent flair was in treated with prednisone 40mg daily and then tapered. prednisone 40mg po daily was started, with minimal relief. rheumatology was consulted and recommended solumedrol 40mg iv daily, as thought that prednisone may not be getting absorbed well. she was continued on allopurinol 300mg daily. xr of left hand was without abnormality. she was discharged to rehab on a 10 day course of solumedrol daily, with f/u with her pcp. . # partial sbo: pt with her chronic abdominal pain and some distention which she notes since . ct abdomen showed partial sbo, with transition point in the rlq. she continued to have bowel movements, and was never obstipated. tube feeds were briefly held but then restarted. cause of psbo is thought to be adhesions, though she is a poor surgical candidate and as it seemed to resolve, did not pursue surgical intervention. symptomatically treated with simethicone, zofran, and bowel regimen po and pr. bowel pain was resolved on discharge. . # c dif infection. pt initially with abd pain and had psbo, then developed diffuse diarrhea, c dif positive. she was treated with flagyl for a 10 day total course, and diarrhea resolved. . # pseudomonas growing from trach culture : by the time this culture from came back for pseudomonas (on ), she had been treated for c dif and had been afebrile, breathing at new baseline, and had no leukocytosis for several days. thus, does not appear that she has pna, so abx not started. she is likely colonized with pseudomonas. . # hypernatremia: appears to be chronic in nature, discharged with na 148 (range: 146-150), 150 on admission. most likely poor access to water and volume depletion. resolved with free water boluses per dopoff when taking pos. . # copd/osa s/p tracheostomy: pt with copd, requiring tracheostomy for resp failure in and readmission for trach mafunctioning requiring replacement of trach. also with known osa and right sided heart failure. she was continued on psv at night through trach, and on trach mask during the day. also continued on ipratropium, albuterol, and fluticasone. . # cor pulmonale/right sided heart failure: tte in showed estimated right atrial pressure of mmhg; lv systolic function was hyperdynamic (ef 70-80%), and the rv free wall was hypertrophied with marked dilation and with depressed free wall contractility consistent with severe right-sided dysfunction with cor pulmonale resulting from severe pulmonary htn and osa. she was continued on home diruetics of torsemide 40mg daily and metolazone . # acute kidney injury: baseline cr around 1.0, was 1.4 during most of admission. urine lytes suggested she was dry, though her respiratory status is very tenuous and we were hesitant to pull back her home dose of diuretics. she may benefit from discontinuation of metalozone, though this should be done in setting of long-term follow up given the potential for her respiratory status to decline. . # pumonary artery hypertension: type iii chronic hypoxemia from obstructive sleep apnea and copd. sildenafil had been dc'd in with no noted significant changes. . # iron deficiency anemia: chronic. hct 28 on admission, in mid 20's during admission. at baseline. continued iron supplementation. . # dm2: has not required long acting in the past, gave iss while in house. . ======================= transitional issues # pt sent out on methylprednisolone 40mg iv daily for 10 days. she will see her pcp ( ) on , and response to steroids and need for taper can be assessed at that time. # f/u kidney function at pcp visit, consider going down on or holding metolazone medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 1-2 puffs inhalation every four (4) hours. 2. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler : 1-2 puffs inhalation every six (6) hours. 3. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po once a day as needed for constipation. 5. allopurinol 100 mg tablet : three (3) tablet po daily (daily). 6. metolazone 5 mg tablet : one (1) tablet po twice a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 8. torsemide 20 mg tablet : two (2) tablet po twice a day. 9. roxicet 5-325 mg/5 ml solution : ml po every six (6) hours as needed for pain. disp:*400 ml* refills:*0* 10. simethicone 40 mg/0.6 ml drops, suspension : eighty (80) mg po four times a day as needed for indigestion. 11. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg/5 ml elixir : five (5) ml po three times a day. 12. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : five (5) ml po once a day. 13. miralax 17 gram/dose powder : seventeen (17) grams po once a day. 14. insulin per insulin sliding scale worksheet. 15. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. discharge medications: 1. metolazone 5 mg tablet : one (1) tablet po bid (2 times a day). 2. torsemide 20 mg tablet : two (2) tablet po bid (2 times a day). 3. allopurinol 300 mg tablet : one (1) tablet po daily (daily). 4. methylprednisolone sodium succ 40 mg recon soln : one (1) recon soln injection q24h (every 24 hours) for 9 days. 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : two (2) puffs inhalation every four (4) hours. 6. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler : inhalation every six (6) hours. 7. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 8. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 9. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 10. oxycodone-acetaminophen 5-325 mg/5 ml solution : 5-10 mls po q6h (every 6 hours) as needed for pain. 11. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po qid (4 times a day) as needed for indigestion/abdominal pain. 12. insulin lispro 100 unit/ml solution : . . subcutaneous asdir (as directed): per sliding scale. 13. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : one (1) po daily (daily). 14. polyethylene glycol 3350 17 gram/dose powder : one (1) po daily (daily). 15. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 16. ondansetron hcl (pf) 4 mg/2 ml solution : one (1) injection q8h (every 8 hours) as needed for nausea, vomiting. 17. metronidazole 500 mg tablet : one (1) tablet po q8h (every 8 hours) for 7 days. tablet(s) 18. respiratory support mechanical ventilation: cpap w/ & w/o ps pressure support level: 15-20 cm/h2o peep: 5 cm/h2o fio2: 30 % psv as needed for increased work of breathing/hypoventilation when sleeping. discharge disposition: extended care facility: - discharge diagnosis: partial small bowel obstruction; c dif infection; pulmonary hypertension; obesity hypoventilation syndrome discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear ms , it was a pleasure taking care of you at . you were admitted for abdominal pain and concern for respiratory distress. you were found to have a partial small bowel obstruction, and you were treated medically for this. your respiratory status was found to be at baseline, and no major new interventions were made. you were also found to have an intestinal infection called "c dif", and for this you will take antibiotics. the following changes were made to your medications ** start flagyl (antibiotic) 3 times daily for 8 more days please follow up with your doctors the section below. appointments have been made for you. followup instructions: department: when: tuesday at 10:20 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: rheumatology when: monday at 4:00 pm with: , md building: lm bldg () campus: west best parking: garage department: when: monday at 9:50 am with: building: campus: east best parking: garage department: when: monday at 10:30 am with: building: campus: east best parking: garage md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours enteral infusion of concentrated nutritional substances diagnoses: obstructive sleep apnea (adult)(pediatric) urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified other chronic pulmonary heart diseases intestinal infection due to clostridium difficile morbid obesity iron deficiency anemia, unspecified hypoxemia chronic obstructive asthma, unspecified hyperosmolality and/or hypernatremia chronic diastolic heart failure acute gouty arthropathy tracheostomy status intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) dependence on respirator, status bariatric surgery status osteoarthrosis, localized, not specified whether primary or secondary, lower leg body mass index 50.0-59.9, adult rosacea obesity hypoventilation syndrome 

Answer: The patient is high likely exposed to