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: no known allergies / adverse drug reactions attending: chief complaint: respiratory distress, fevers major surgical or invasive procedure: intubation -- rij cvl -- intubation -- picc placement -- history of present illness: 64yof with history of advanced ms, schizophrenia, and dementia who presents from with fevers to 102 and respiratory distress in the setting of cough and ?aspiration. pt unable to given history given intubation however according to ed signout and records, pt appeared unwell this evening and was sent to ed for further evaluation. . in the , pt initially triggered for tachypnea to 30s and tachycardia to 170s. she was also febrile to 105. pt was immediately intubated for respiratory distress. post intubation cxr demonstrated rml opacity. ua was also showed concerning for uti. labs were significant for leukocytosis to 15 with prominent bandemia (15%), lactate of 5.3, as well as mg to 1.3, ca 7.3 and phos of 2.2. pt was given 4lns, vancomycin, and zosyn. maps were notable to be in low 60s while on propofol so switched to fent/midaz with maps increasing to mid 60s. cvp was not recorded. maps continue drift downward and pt was started norepinephrine. prior to transfer patient developed small amount of "burgundy colored output with coffee grounds," which cleared with 100cc of ns. pt was then transferred to icu for further management. vs prior to transfer were temp 100.6 hr 107 bp 102/60 rr 18, satting 100% on cmv 500x18 with peep of 5 and fio2 of 60%. . of note patient was admitted on for urosepsis and with fevers and sepsis patient began seizing while at . neuro was consulted who thought seizures were precipitated by sepsis and was continued on home depakote. . on arrival to the icu, travelling nurse stated there was some concern for "seizure like activity" as patient was making jarring head movements. patient was intubated and sedated. pt not following commands. past medical history: advanced multiple sclerosis htn advanced schizophrenia dm, type ii hyperlipidemia tardive dyskinesias secondary to longterm neuroleptic use dementia history of seizure disorder, h/o of at least 1 episode of status epilepticus in ' triggered by pna. per most recent seizure was 2 months ago. history of frequent utis and urosepsis - she is usually treated at , but family unhappy with care there. social history: her son and are co-guardians. currently in in army. she lives at center (, . at baseline, she is alert and will respond to her name and will occasionally say "yes" when asked questions and tracks providers with eyes. she does not say any other words. she does not move at all. per notes, hears and sees adequates, chronic bowel and bladder incontinence. no chronic foley. non-ambulatory. needs assistance with all adls. institutionalized for at least 10-15 years. family history: unknown. physical exam: admission physical exam: vitals: 96.6 116/76 111 18 100% on cmv 500x18 peep 5, fio2 60% general: intubated, sedated heent: sclera anicteric, mmm, oropharynx clear, perrla neck: supple, jvp not elevated, no lad, right ij in place lungs: coarse breath sounds, rhonchi in mid right posterior field, underlying crackle at right base cv: tachycardic regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, g-tube in place gu: no foley ext: cool distal ext, warmer proximally, 2+ pulses, no clubbing, cyanosis or edema neuro: sedated, withdrawals to painful stimuli . pertinent results: 9:57 pm blood culture source: line-picc. **final report ** blood culture, routine (final ): klebsiella oxytoca. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . pseudomonas aeruginosa. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella oxytoca | pseudomonas aeruginosa | | amikacin-------------- <=2 s ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- <=1 s 32 r ceftazidime----------- 2 s =>64 r ceftriaxone----------- 2 s ciprofloxacin--------- =>4 r i gentamicin------------ =>16 r 2 s meropenem-------------<=0.25 s 1 s piperacillin/tazo----- r r tobramycin------------ 8 i <=1 s trimethoprim/sulfa---- <=1 s 3:50 am blood culture #2. **final report ** blood culture, routine (final ): no growth. 7:04 pm blood culture source: line-central. **final report ** blood culture, routine (final ): no growth. 7:30 am blood culture set#1. **final report ** blood culture, routine (final ): no growth. 6:06 pm sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. sparse growth. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 4 s ciprofloxacin--------- i gentamicin------------ <=1 s meropenem------------- =>16 r piperacillin/tazo----- s tobramycin------------ <=1 s 3:30 pm urine source: catheter. **final report ** urine culture (final ): no growth. 08:36pm hct-29.4* 07:39am glucose-145* urea n-12 creat-0.4 sodium-139 potassium-2.9* chloride-110* total co2-18* anion gap-14 07:39am alt(sgpt)-5 ast(sgot)-14 ld(ldh)-189 ck(cpk)-92 alk phos-42 tot bili-0.3 07:39am albumin-2.1* calcium-6.6* phosphate-2.2* magnesium-1.9 07:39am valproate-48* 07:39am wbc-19.0* rbc-3.47* hgb-9.6* hct-29.2* mcv-84 mch-27.8 mchc-33.1 rdw-15.6* 07:39am neuts-58 bands-10* lymphs-21 monos-9 eos-0 basos-0 atyps-0 metas-2* myelos-0 07:34am lactate-5.3* 04:57am blood wbc-8.6 rbc-3.06* hgb-8.9* hct-26.0* mcv-85 mch-29.1 mchc-34.2 rdw-16.4* plt ct-568* 04:57am blood glucose-166* urean-16 creat-0.6 na-138 k-3.5 cl-102 hco3-29 angap-11 02:56am blood alt-12 ast-28 ld(ldh)-296* alkphos-62 totbili-0.2 12:00pm blood ck-mb-4 ctropnt-<0.01 07:39am blood ck-mb-2 ctropnt-<0.01 03:10am blood ck-mb-1 ctropnt-<0.01 05:52am blood calcium-8.4 phos-3.2 mg-2.1 01:26am blood tobra-9.0 04:57am blood valproa-23* 05:52am blood valproa-20* imaging ct chest/abd/pelvis () final report indication: polymicrobial bacteremia, assess for intra-abdominal infection. technique: mdct-acquired axial images were obtained from the thoracic inlet to the pubic symphysis after the administration of intravenous and oral contrast. coronal and sagittal reformations were prepared. comparisons: none available. ct of the chest with contrast: thyroid gland is normal in appearance with symmetric enhancement. the aorta and major branches are patent with normal three-vessel arch. left-sided picc line is seen terminating in the proximal svc. mediastinum is unremarkable. the heart and pericardium are normal, without pericardial effusion. the esophagus is normal. the trachea and central airways are patent to the segmental level. nodular and ground glass opacities in the left upper lobe is worrisome for infective process. retrocardiac opacitiy, likely atelectasis, is demonstrated. there is no pleural effusion or pneumothorax. 1 cm left axillary node is noted with normal fatty hilum. no other enlarged nodes are seen by ct criteria. ct of the abdomen with contrast: please note, assessment is limited due to the fact that the arms are down. the liver is normal in attenuation without focal lesion, intra- or extra-hepatic biliary ductal dilation. the gallbladder is minimally distended. the pancreas, spleen, and bilateral adrenal glands are unremarkable. the kidneys enhance symmetrically, though excretory phase is not fully imaged as contrast is not in the ureters, though it is in the collecting systems. stomach is nondistended with gastrostomy tube noted. the stomach and small bowel are unremarkable. there is no free air or free fluid in the abdomen. there is no retroperitoneal or mesenteric lymphadenopathy. the aorta and major branches appear patent with moderate atherosclerotic calcification. ct of the pelvis with contrast: the bladder is somewhat decompressed with foley and air inside. the uterus and adnexae are unremarkable. the rectum is normal. there is no free pelvic fluid. there is no pelvic or inguinal lymphadenopathy. osseous structures: there is no lytic or sclerotic bony lesion concerning for osseous malignant process. impression: patchy opacification in the left upper lobe is concerning for pneumonia or aspiration. retrocardiac opacity, likely atelectasis, cannot exclude infection. portable cxr () history: extubated. findings: in comparison with study of , the endotracheal tube has been removed though the central catheter remains in place. there are streaks of atelectasis at the left base, but the lungs are otherwise clear with no evidence of pulmonary vascular congestion or cardiomegaly or pleural effusion. brief hospital course: 64 y.o. woman with advanced ms, schizophrenia, dementia, dysphagia who came in from on with resp distress, fevers, found to be in septic shock due to right middle lobe pneumonia from a possible aspiration. she was intubated on presentation, extubated and transferred to the floor on on ra, reintubated on and extubated , transferred back to the floor on . her course was complicated by (thought to be secondary to atn) - this ultimately resolved. . #hcap/ gnr bacteremia -the patient presented with respiratory failure requiring intubation and was treated for pneumonia with vancomycin and zosyn. she was pressors while in the icu but was weaned off. pt completed a 7 day course of vanc/zosyn but on she had a fever of 101.1 with blood cultures from the picc line growing gnr - picc removed, tip cultured negative. pneumonia felt to be likely source. urine cultures showed only fecal contamination. sputum cultures did not show any specific organism for the pneumonia. blood cultures grew pseudomonas and klebsiella, initially started on meropenem, but then switched to tobramycin and cefepime after the sensitivies returned and infectious disease was consulted. she had a new picc placed and will need to have 14 day courses of tobramycin () for blood stream infection and cefepime for hcap/vap (). given her thick secretions, she has been started on a scopolamine patch with good effect. she is currently stable on room air. the health care proxy, , is aware that pt is at high risk for recurrent episodes of aspiration and that the patient may benefit from tracheostomy. the icu team discussed this extensively with the hcp, however, at this time, she is deferring this option. this is partly because the patient's son is also a hcp for the pt, but is currently serving in the army in , and is not available to participate in the discussion. . #htn:the patient was initially hypotensive on pressors but then was weaned off and subsequently restarted on her metoprolol at higher dose to avoid her acei due to . she was restarted lisinopril at 5 mg po daily when her cr normalized but cr rose slightly so it was d/ced and metoprolol was uptitrated. she briefly required the addition of amlodipine 5 mg for bp control. her hypertension is currently well controlled with metoprolol only. . #: it was initially felt to be likely atn. creatinine downtrended to 1.1 with ivf. it rose slightly with reinitiation of her ace-i, so it has been discontinued indefinitely until she is followed-up as an outpatient. she maintained good output and is incontinent at baseline. random bladder scan showed only 130 ml residual. her bun/cr should continue to be monitored, especially since she is on tobramycin which has nephrotoxicity. if her renal function declines, she will need her tobramycin levels checked for possible dosing readjustment. . #gi bleed: the patient was noted to have a small amt coffee ground emesis in ed which cleared w/ 100 cc lavage. it was presumed stress gastritis and she was placed on a ppi. her hematocrit did downtrend to 20.9, but she responded appropriately to 1 unit prbc blood transfusion and has remained stable since. a ct chest/abdomen/pelvis did not show any source of active bleeding. . #seizure disorder: the patient has a history of seizures in the setting of sepsis. although there was a question of seizure like activity at admission, she had no further episodes after extubation and was continued on her depakote. neurology was consulted, they did not think she was having breakthrough seizures. they did increase her depakote dose after levels were low, likely due to interaction with meropenem. her goal depakote levels are 50 - 60, and she will require repeat blood levels. she had a bedside eeg that on prelim read shows no status epilepticus. . #dm: given her , metformin was discontinued and she is being treated with a lispro sliding scale. . #fen:the patient was restarted on her tube feeds for a goal of 60ml/hr of promote with fiber at 20 hrs/day. however, it was changed to glucerna with beneprotein as she had elevated blood sugars. . #access: she initially had a central line in the icu and had a picc line placed. when bacteremic, the picc line was d/ced and a new central line was placed on , and this was ultimately removed and new picc () placed after being surveillance culture negative for 72 hours. . code status: full code . guardian: ( lives in - healthcare center . transitional issues: 1. she will need to have her depakote levels monitored closely, optimally daily. her dose was increasd from 2000mg to 2250mg during this admission. her goal trough levels are 50-60. 2. she will need to have her renal function monitored with every other day bun/cr while she is on the tobramycin. 3. she will need to be restarted on her lisinopril and metformin if her renal function remains stable. medications on admission: 1. mom 400mg/5ml 20cc via gtube 30cc qod 2. lisinopril 5mg daily 3. vitamin c 500mg/5cc 5cc daily 4. 1g 5. clonazepam 0.5mg 6. docusate 100mg 7. metformin 1000mg 8. metoprolol tartrate 50mg 9. senna 8.6mg 2 tabs 10. valproic acid 2g 11. hyoscyamine 0.125cc q8h 12. simvastatin 20mg qhs 13. ducolax prn 14. fleet enema prn 15. albuterol prn 16. ipratropium prn 17. apap 325 prn 18. promote wth fiber @ 60 cc/hr, 20 hrs/day, off at 1000 on at 1400 19. flushes 300cc water q6h 20. flush 50cc pre and post meds discharge medications: 1. 1 gram tablet : one (1) tablet po bid (2 times a day). 2. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for wheeze. 4. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for wheeze. 5. ergocalciferol (vitamin d2) 50,000 unit capsule : one (1) capsule po monthly on the 16th (). 6. therapeutic multivitamin liquid : five (5) ml po daily (daily). 7. clonazepam 0.5 mg tablet : one (1) tablet po bid (2 times a day). 8. valproic acid (as sodium salt) 250 mg/5 ml syrup : 2250 (2250) mg po q12h (every 12 hours). 9. simvastatin 10 mg tablet : two (2) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet : two (2) tablet po twice a day: hold for hr <55, sbp<110. 11. heparin, porcine (pf) 10 unit/ml syringe : two (2) ml intravenous once a day: picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. . 12. insulin lispro 100 unit/ml solution : as dir by sliding scale units, insulin subcutaneous every six (6) hours: for blood glucose: 151-200: 2 units sq 201-250: 4 units sq 251-300: 6 units sq 13. tobramycin sulfate 60 mg/6 ml solution : four hundred sixty (460) mg intravenous q48 hours for 5 days. 14. cefepime 2 gram recon soln : two (2) grams intravenous every eight (8) hours for 9 days. 15. scopolamine base 1.5 mg patch 72 hr : one (1) transdermal every seventy-two (72) hours. 16. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 17. vitamin c 500 mg/5 ml syrup : five (5) ml po once a day. 18. senna 8.6 mg capsule : two (2) capsule po twice a day. 19. hyoscyamine sulfate 0.125 mg tablet : one (1) tablet po every eight (8) hours. 20. colace 100 mg capsule : one (1) capsule po twice a day. capsule(s) 21. outpatient lab work check daily depakote trough levels (goal 50 - 60) 22. outpatient lab work check every other day bun/cr while on tobramycin discharge disposition: extended care facility: healthcare center - discharge diagnosis: healthcare-associated pneumonia klebsiella and pseudomonal bacteremia discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: you were admitted with pneumonia and bacteremia (blood-borne infection). your lisinopril was also stopped due to your kidney injury that resulted from this severe infection. you will need to complete a course of iv antibiotics as an outpatient. you were intubated and stayed twice in the icu on this admission. please stop taking your lisinopril and metformin, due to your recent kidney injury. your outpatient pcp will determine if you should be restarted on these medications. you will need to have your depakote levels and renal function (bun/cr) monitored. depakote will need to be checked daily till levels are therapeutic and stable (goal troughs are 50 - 60) and bun/cr checked every other day while on tobramycin. followup instructions: you will be followed by your physician at the nursing home. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances central venous catheter placement with guidance diagnoses: acidosis anemia, unspecified acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified unspecified essential hypertension friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia severe sepsis other persistent mental disorders due to conditions classified elsewhere other and unspecified hyperlipidemia acute respiratory failure pneumonitis due to inhalation of food or vomitus bacteremia septic shock unspecified gastritis and gastroduodenitis, with hemorrhage epilepsy, unspecified, without mention of intractable epilepsy multiple sclerosis hyperosmolality and/or hypernatremia ventilator associated pneumonia gastrostomy status pseudomonas infection in conditions classified elsewhere and of unspecified site other and unspecified anticonvulsants causing adverse effects in therapeutic use schizophrenic disorders, residual type, chronic subacute dyskinesia due to drugs 

Answer: The patient is high likely exposed to