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: altered mental status, hypoxia major surgical or invasive procedure: tracheostomy and trach tube placement history of present illness: mr. is an 87 yo man with a recent stroke with persistent r near-hemiplegia s/p peg placement, dm2, ckd (baseline cr 1.6-2) who presented from his nursing home today minimally repsonsive. . upon arrival to the ed, he remained minimally responsive and was intubated for airway protection. his initial vss were 98.1, 84, 96/53, 80, 94%. a cxr demonstrated a questionable new opacity at the right base. a u/a was suggestive of uti, and he was covered broadly for both uti and pna with vancomycin, ceftazadime and levofloxacin. a central line was placed. . no further history was available. among the pt's outside records were lab reports indicating that his cr was 2.1 on and had risen to 4.2 on . past medical history: - diabetes mellitus - chronic kidney disease, cr 1.6-2 - hypertension - dyslipidemia - aortic insufficiency - thoracic aortic aneurysm - osteoarthritis. - first degree a-v delay - gerd - bph - nephrolithiasis - cataracts - ventral hernia - history of malaria - baseline chronic anemia - s/p peg tube placement social history: no smoking, occasional alcohol, no drug use. family history: non-contributory physical exam: vs: temp: 96.9 bp: 109/47 hr: 100 rr: 16 o2sat 100% gen: sedated, intubated heent: perrl, l eye cloudy, anicteric, mm dry neck: supple, no jvd resp: cta b/l anteriorly with good air movement throughout cv: tachycardic, s1 and s2 wnl, no m/r/g abd: g-tube without surrounding erythema, nd, nabs, soft, no masses or hepatosplenomegaly ext: no c/c/e, warm, good pulses skin: no rashes/no jaundice pertinent results: 06:00pm wbc-13.5* rbc-3.65* hgb-10.8* hct-32.1* mcv-88# mch-29.6 mchc-33.7 rdw-14.8 06:00pm neuts-70.0 lymphs-25.1 monos-3.6 eos-1.3 basos-0.2 06:00pm pt-15.2* ptt-26.9 inr(pt)-1.3* 06:00pm plt count-192 . 06:00pm glucose-147* urea n-120* creat-4.3*# sodium-156* potassium-4.7 chloride-116* total co2-32 anion gap-13 06:00pm alt(sgpt)-17 ast(sgot)-16 ld(ldh)-177 ck(cpk)-160 alk phos-93 amylase-160* tot bili-0.2 lipase-29 . 06:17pm lactate-1.3 . 06:50pm urine rbc-* wbc-21-50* bacteria-mod yeast-none epi-<1 06:50pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-sm 06:50pm urine color-yellow appear-clear sp -1.015 06:50pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg . cardiology report ecg study date of 6:44:40 pm sinus rhythm with borderline sinus tachycardia. brief pause - probably due to non-conducted atrial premature beat. borderline first degree a-v delay. left atrial abnormality. left anterior fascicular block. since the previous tracing of atrial ectopy is present. . intervals axes rate pr qrs qt/qtc p qrs t 99 0 100 350/418 0 -59 56 ========================== on discharge: . recent studies chest x-ray findings: in comparison with the study of , the patient has taken a much better inspiration. the opacification at the right base almost completely cleared and the hemidiaphragm is sharply seen. mild increased opacification persists at the left base. the cardiac silhouette remains somewhat enlarged and there is indistinctness of pulmonary vessels that could be a manifestation of vascular congestion. . tracheostomy tube and picc line remain in place. . recent lab values: 03:47am blood wbc-11.5* rbc-3.03* hgb-8.8* hct-26.3* mcv-87 mch-28.9 mchc-33.2 rdw-14.7 plt ct-240 . 03:47am blood pt-14.5* ptt-39.6* inr(pt)-1.3* 01:55pm blood glucose-188* urean-46* creat-2.4* na-137 k-3.8 cl-106 hco3-27 angap-8 01:55pm blood calcium-7.7* phos-3.6 mg-2.1 . 04:43pm urine blood-tr nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 04:43pm urine rbc-1 wbc-1 bacteri-few yeast-none epi-0 . microbiology: c diff toxin + brief hospital course: a/p: 87 yo man with recent stroke with persistent near-hemiplegia and peg placement, dm2, ckd presents from nh with delirium, acute renal failure, ? pna and ? uti. . # hypoxemic respiratory failure: mr was intubated for airway protection and hypoxemia on arrival. his x-ray was read as a possible right lower lobe pneumonia, and then evolved with perihilar opacities. he was started on levofloxacin, ceftazidime and vancomycin to treat a healthcare-associated pneumonia (given recent nursing home residence) and possible uti. by the 12th (day ) his x-ray was no longer showing a clear opacity, but he remained ventilator dependent with copious oral and pulmonary secretions. he was titrated down to fio2 of 0.40, pressure support of 10 and peep of 5 by the 14th, and has been on these settings since then. . despite multiple spontaneous breathing trials, his rsbi never declined to a level in which extubation appeared reasonable. accordingly, after discussion with his family, he had a bedside tracheostomy on and was on a trach tube thereafter; still, his vent settings remained the same and he remained unable to tolerate spontaneous breathing trials. in the last two days of his admission we started 4x/daily trach mask trials for 20-30 minutes as tolerated in order to see whether this would help his pulmonary condition. we also began to more aggressively diurese him (see below) which appeared to help resolve edema seen on his x-ray although his clinical condition did not change substantially in the short term. hopefully with further diuresis he can wean from the vent as there is no clear other reason he should not be able to. . # c. difficile infection. on the night before discharge, mr was noted to have foul-smelling mucoid stool, and c. diff was sent. this returned positive, and flagyl was started. this was likely caught very early in the infection, which was most likely secondary to c. diff regrowth soon after the discontinuation of his 14 day course of levo/ceftaz/vanco for pneumonia, which had likely depleted much of his normal flora. is day 1 of 14 for treatment of this. . # altered mental status: he was lethargic and unresponsive on arrival. we considered several possible etiologies including toxic/metabolic encephalopathy, uremia, hypernatremia, pna, uti, and meningitis. his bun was remarkably high (baseline at last d/c was 20), though he had no pericardial rub on exam. hypernatremia likely volume depletion. his neck was supple on exam. a ct head was negative for new processes although it did show an old pontine infarct. a clear etiology was not identified since his infection and hypernatremia were both treated in the first days of his admission; his mental status appeared to clear somewhat although it was difficult to tell (particularly in the setting of requiring mechanical ventilation) what his baseline was and whether he had returned to it. he had some clearly lucid periods in which he was able to shake his head or nod in response to questions and even occasionally to attempt to mouth words, though on the day of discharge he was arousable and tracked and registered his examiners but did not clearly answer questions. (he had received a one-time dose of ativan in the night prior.) whether he might continue to have improvement as other aspects of his health improve is not clear. we would suggest low-dose haldol if his agitation continues. we have been attempting to avoid sedation in order to try to work further towards weaning from the vent. . # acute renal failure: mr creatinine was quite elevated from baseline on arrival at 4.3, with a bun of 120; we hydrated him aggressively and saw a progressive improvement in his creatinine over the next several days. his urine from his inital presentation grew out coag-negative staph, resistant to oxacillin and levofloxacin but sensitive to the vancomycin we had started by that time. we judged the initial presentation of renal failure to be most likely secondary to volume depletion given bun/cr ratio and the strong possibility of falling behind on intake at the nursing home in the setting of an acute illness. we held his lisinopril and other antihypertensives, and dosed medicines renally as appropriate. . his creatinine rose again in the last three days of admission (to 2.4 on ) in the setting of gentle efforts at diuresis, with the hope of getting his pulmonary and peripheral edema to resolve. we consulted the renal team which agreed with further efforts at diuresis, and we increased our doses of lasix, which we titrated to a fluid balance of even to -500 cc/day, although we only actually achieved a negative fluid balance on the last day of admission. he will likely need further increasingly aggressive diuresis if he does not begin to autodiurese more vigorously, and will likely need furosemide plus another . . # hypernatremia: he was hypernatremic on arrival; this corrected with consistent hydration and free water boluses in his tube feeds. . # s/p cva: per neuro d/c summary, "at the time of discharge he could withdraw his right leg slightly, with plegia in the right arm and a right facial droop, as well as dysarthria. as now is sedated, unable to perform adequate neuro exam. - continue clopidogrel, atorvastatin . # leukocytosis: likely . . # dm: we held his po hypoglycemics. we kept him on an insulin sliding scale, and also added glargine for baseline level. . # anemia: he has most recently been written for an outpatient dose of 40 mcg of aranesp every other week, likely ckd. we held this during this admission but this could be restarted. he received a unit of packed red blood cells on for a hematocrit of 21.4 which was dropping in the setting of aggressive hydration (a source of bleeding was not identified then or in retrospect). he also received a unit of packed red blood cells on for a hematocrit of 21.9, with the expectation that this would continue to drop, he would be leaving the icu soon, and evaluation of his post-transfusion stability would be helpful before transfer. otherwise his hematocrit transfusion criteria could be <21. . # gerd: lansoprazole 30 daily . # f/e/n: ivf. repleted lytes prn. tube feeds; we changed this during the last two days of his admission to reduce his total fluid volume, and on discharge he was on replete w/fiber, full strength; with a goal rate of 65 ml/hr. his albumin did decline during this admission although the contribution of nutrition vs acute illness was difficult to know, and should be followed after discharge. . # ppx: bowel regimen (should hold with diarrhea), sq heparin . # access: right subclavian central line, pivs . # dispo: to a rehabilitation facility with ventilator capacity . # code status: full (confirmed with daughter, ) . medications on admission: aranesp amlodipine 10 daily atorvastatin 40 daily clopidogrel 75 daily vitamin d 1000 daily ferrous sulfate 325 daily glipizide 10 daily lisinopril 7.5 mg daily metoprolol 50 acetaminophen prn omeprazole 20 senna 2 tabs insulin . discharge medications: 1. folic acid 1 mg tablet : one (1) tablet po daily (daily). 2. atorvastatin 80 mg tablet : one (1) tablet po daily (daily). 3. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day): hold for diarrhea. 4. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 5. cholecalciferol (vitamin d3) 400 unit tablet : one (1) tablet po daily (daily). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 7. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily): hold for diarrhea. 8. metoclopramide 10 mg tablet : 0.5 tablet po qidachs (4 times a day (before meals and at bedtime)) as needed for for regurgitation/high residuals. 9. albuterol 90 mcg/actuation aerosol : 1-2 puffs inhalation q6h (every 6 hours). 10. ipratropium bromide 17 mcg/actuation aerosol : two (2) puff inhalation qid (4 times a day). 11. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 12. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for fever or pain: notify physician if patient has fever. 13. metronidazole 500 mg tablet : one (1) tablet po tid (3 times a day). 14. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 15. ferrous sulfate 300 mg/5 ml liquid : one (1) po daily (daily). 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 17. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 18. haloperidol lactate 5 mg/ml solution : 0.25 mg injection q4h (every 4 hours) as needed for agitation. 19. plan for diuresis consider continuing diuresis with furosemide 100-160 up to to reach fluid balance goal of -500 cc/day 20. aranesp (polysorbate) 40 mcg/0.4 ml syringe : one (1) injection injection every other week. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: pneumonia, pulmonary edema, c. diff infection discharge condition: stable discharge instructions: you are being discharged to the , where your care can continue. see below for instructions to providers. followup instructions: key issues for discharge: * attempt to further diurese patient who gained considerable fluid weight during his icu admission; this may also improve respiratory status. * weaning from vent as tolerated * treatment of c. diff infection; day 1 of 14 day course of metronidazole is * ongoing evaluation of mental status; not clear what new baseline will be at this point. . he has the following appointments: renal follow-up: , md phone: date/time: 4:00 procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances other bronchoscopy temporary tracheostomy replacement of gastrostomy tube diagnoses: pneumonia, organism unspecified anemia in chronic kidney disease esophageal reflux acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified thoracic aneurysm without mention of rupture hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified aortic valve disorders hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure intestinal infection due to clostridium difficile other left bundle branch block late effects of cerebrovascular disease, hemiplegia affecting unspecified side late effects of cerebrovascular disease, other speech and language deficits other and unspecified special symptoms or syndromes, not elsewhere classified hyperosmolality and/or hypernatremia staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled first degree atrioventricular block unspecified cataract other late effects of cerebrovascular disease, facial weakness ventral, unspecified, hernia without mention of obstruction or gangrene other diuretics causing adverse effects in therapeutic use edema other late effects of cerebrovascular disease, dysphagia attention to other artificial opening of digestive tract profound impairment, one eye, impairment level not further specified 

Answer: The patient is high likely exposed to