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 attending: chief complaint: diabetic ketoacidosis, non st segment myocardial infarction major surgical or invasive procedure: intubation and mechanical ventilation tracheostomy peg tube placement transfusions history of present illness: ms. is a 74 year old female with a past medical history of diabetes melitis type 2, now insulin dependent, hyperlipid, - disease, and dementia who presented to an out side hospital with uncontrolled finger stick glucoses (500s despite sliding scale insulin at home), lethargy, mental status changes, and nausea and emesis (1 day prior). she was found to be in diabetic ketoacidosis, with a urinalysis positive for infection, ecg with diffuse t wave inversions, ck 700, mb 129, and tropi 33. she was given aspirin, subcutaneous lovenox, integrilin, levofloxacin, subcutaneous insulin and transfered to for further management & consideration of cardiac catheterization. past medical history: dm2 on insulin hypercholesterolemia dementia/ disease (an inherited spinocerebellar ataxia: progressive neurological disorder of ataxia, peripheral neuropathy) (no known htn) social history: prior to admission the patient was living at home with her daughter. the patient was bedridden and very dependent on family members to care for her. she has a significant smoking history of 50 pack years, though she quit smoking 10 years ago. denies etoh or other drugs. family history: - disease. physical exam: t: 98.5 hr: 89 bp: 129/50 rr: 21 o2sat 100% 1l nc gen: cachectic female. heent: mm dry. no sceral icterus. eomi. neck: supple, no lymphadenopathy. no jvd. chest: pectus carinarum cv: rrr, ii/vi systolic murmur heard best at llsb. lungs: course breath sounds bilaterally. abd: thin, s/nt/nd. +bs. no hsm ext: no c/c/e. pulses 2+ femoral, 1+ bilaterally dp/pt. neuro: oriented to person. non-focal. strength 5/5 throughout. maew - alternating contracting muscles in legs and pulling them up to chest. pertinent results: head ct (): limited study secondary to motion artifact with severely limited examination/ of the infratentorial structures and the middle cranial fossa. within the limits of this study, there was no evidence of major vascular territorial infarction or acute intracranial hemorrhage. * eeg (): markedly abnormal eeg due to the low voltage slow background with occasional surpressive bursts and with runs of uniformly distributed alpha frequencies throughout. overall, the tracing indicates a widespread and moderately severe encephalopathy. this can come from anoxia or severe metabolic derangements, but the widespread alpha frequency suggests medication effect. there were no epileptiform features. 11:56pm ck(cpk)-1453* 11:56pm ck-mb-129* mb indx-8.9* ctropnt-3.77* 11:56pm wbc-20.3* rbc-3.82* hgb-11.5* hct-34.4* mcv-90 mch-30.2 mchc-33.5 rdw-14.0 11:56pm urine blood-lge nitrite-neg protein-tr glucose-1000 ketone-15 bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 11:56pm urine rbc-62* wbc-20* bacteria-occ yeast-none epi-2 9:04 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. heavy growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin------------- 0.5 s penicillin------------ =>0.5 r brief hospital course: overall it was hypothesized that the patient developed an infection (i.e., urinary tract infection) leading to dka & had a non st elevation myocardial infarction in this setting of acute infection & metabolic abnormalities. 1. cardiovascular: a. cad: nstemi - ecg changes and + cardiac enzymes; ck peaked at 1450 and then trended down. ck did rise again later after pt was intubated, but mb and troponin continued to trend down. because the patient was not felt to be a good candidate for catheterization, she was managed medically. she was started on asa, plavix, and her statin was increased to 20 per day. she was initially started on metoprolol to control heart rate and blood pressure, and when her blood pressure allowed she was given captopril. she was given lovenox for 48 hours but no integrillin since she was not going to catheterization. the aspirin and plavix were held during periods when concerns for intracranial bleeding were present, but then restarted when this was felt to be less likely. later, ms. pulled out her ng tube repeatedly and it was not possible to maintain her on plavix since it cannot be administered otherwise. her aspirin was continued rectally and other medications were administered intravenously until her peg tube was placed. of note, she had sufficient bleeding around her tracheostomy site that her surgeon had to return to stitch it down. it was thought that hemostasis was difficult to achieve since she was on aspirin and plavix. once her peg was placed, it was decided not to continue her plavix in the interest of preserving hemodynamic stability. b. pump: ef 30-35%; pt initially received aggressive intravenous fluids for diabetic ketoacidosis, and then was diuresed since oxygen saturations dropped and the patient was having more labored breathing. the patient's blood pressures were initially high and would go even higher with agitation. she was maintained on a labetolol gtt for a short time to control these bp's. her labored breathing eventually led to intubation, followed by extubation during a period where her hemodynamics had stablilized, and then re-intubation since pt's breathing was extremely labored on the shovel mask. for the second intubation the patient was given propofol for sedation and her bp dropped acutely. she required 3 pressors (dopamine, neo, levophed) with maps in 70s, sbp in 110s. bedside echo showed no changes after these events. her hemodynamics were gradually stablized and bp eventually became high again. throughout her hospitalization the pt had extremely labile bp's that seemed to be affected by her position and level of agitation. these changes were of unclear etiology and thought to be possibly related to her underlying disease vs. pain. her blood pressure medications were titrated aggressively since she developed flash pulmonary edema nearly each time she became hypertensive, tachycardic, and tachypneic. upon discharge, she was stable and normotensive. c. rhythm: pt was in nsr for most of her hospitalizaton. during the time she was maintained on dopamine, however, ekg's showed a junctional rhythm which resolved when the dopa was weaned. she remained in sinus throughout the remainder of her intensive care unit stay. 2. pulmonary: as discussed above, the pt was intubated on for primary respiratory acidosis with hypercarbic failure. extubated to face mask later on the same day but persistently tachypneic to 30s. tried bipap to no avail. off bipap patient continued to breathe at 30 and breathing looked extremely labored. it was felt that it would be unlikely that the patient would be able to leave the hospital without some kind of respiratory support and so it was collectively decided with the family that a temporary tracheostomy might help her improve yet be more comfortable than the breathing tube. on she was electively intubated (as bridge to peg and trach) with subsequent hypotension requiring 3 pressors as described above. she was stabilized from this and eventually had a tracheostomy placed with a minor bleeding complication due to administration of aspirin and plavix. ms. also suffered a small pneumothorax as a consequence of an attempted right subclavian line. this was followed with serial chest x rays and did not require a chest tube to be placed. it resolved within 2 days. she then developed a methicillin sensitive staph aureus ventilator associated pneumonia. she was started on levofloxacin for a total course of 8 days. 3. endocrine: the patient was admitted in diabetic ketoacidosis with blood glucose 559, ketones & an anion gap of 20 at an outside hospital and only covered with sliding scale insulin there. her anion gap was 15 on arrival. the precipitant was likely infection (urinary tract) and the patient was managed on insulin drip until , after which she was covered with nph and hss. she initially had presented with hypernatremia (na was 150) which was corrected wwith normal saline and normalized. throughout her stay, her blood sugars were very labile and difficult to control although she was on an insulin drip. she was stabilized on glargine 35 units qpm and covered with a regular insulin sliding scale. 4. id: the patient presented with elevated white blood cell count and neutrophilia. her urinalysis was positive at the outside (although with some epithelial cells so it may have been contaminated). she was started on levofloxacin for the urinary tract infection and was treated for 7 days. her chest x ray was initially clear, but then developed a questionable left upper lobe infiltrate. any possible pneumonia would likely have been covered by the levaquin, however, then the patient's blood pressures dropped following intubation and there was a concern that she may have been septic. thus, she was started on ceftazidime, vancomycin, and flagyl to cover wider for the possible pneumonia as well as any line infection with methicillin resistant staph aureus. however, no cultures ever grew out any organism. the patient spiked a few fevers while on these antibiotics, however, then the fevers resolved on their own and all antibiotics were discontinued since no organisms were ever identified. later in her course, ms. developed increasing secretions and clinical decompensation. although she never became febrile and her chest x ray was unchanged, she was started on vancomycin. her sputum was sent for culture and it was determined that she had heavy growth of methicillin sensitive staph aureus. she was de-escalated to levoquin and will finish her 8 day course at the outside rehabilitation facility. following the second day of treatment the patient's mental status and tone improved. 5. neuro: history of disease; per family, initially lethargic at outside hospital (head ct neg there), near baseline on admission to . after extubation, however, pt was more lethargic. she followed some commands but was too drowsy to swallow. her mental status declined until eventually, she did not even respond to noxious stimuli applied to her nailbeds or sternum. her head ct was repeated with no changes seen (no intracranial hemorrhage). she was evaluated by neurology who felt that she may have been having a seizure since she had symptoms concerning for myoclonus and posturing. the eeg was abnormal in that it showed encephalopathy but did not show seizure activity. however, the patient was started on phenytoin since she had been given ativan before the eeg was taken and it thus seizure was able to be completely ruled out. after several days without evidence of seizure activity, the team decided to stop the phenytoin as it was thought that the medication might contribute to the patient's decreased mental status. she slowly became more alert during her course, but would wax and wane continually. eventually she would respond to commands and was occasionally alert and oriented to person and place. it was thought that the etiology to her obtundation was toxic metabolic. 6. lines: the patient was initially managed with peripheral iv's, however, as her condition worsened central access was attempted at the right internal jugular and right subclavian without success. see above pulmonary section for complications. she was thus managed with a right femoral line for several days which was changed to a left femoral line until a picc was placed. * 6. fen: speech/swallow had evaluated the patient before her intubation and had recommended prethickened liquids. however, after her intubation for the second time it was felt that the patient was not able to handle her secretions well and would likely need a peg placed for nutrition as well as for safety reasons. her tracheostomy placement was complicated with some difficulty attaining hemostasis. her peg tube was placed without complications and she was fed through it during the remainder of her hospitalization. upon speech and swallow evaluation of her after placement of the tracheostomy, it was decided that she was not ready for any oral feeds since she appeared to be aspirating her secretions. it was thought that once she was weaned from the ventilator, she could be evaluated again. she should not be given anything by mouth because she is a serious aspiration risk. 7. communication: full code. the family was heavily involved in making decisions about the patient's care and all along expressed wishes for aggressive care. medications on admission: synthyroid 88 mcg once a day lipitor 10 mg once a day 70/30 insulin 24 units qam, 24 units qpm discharge medications: 1. levothyroxine sodium 88 mcg tablet sig: one (1) tablet po qd (once a day). 2. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) as needed. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po qd (once a day) as needed. 6. acetaminophen 160 mg/5 ml elixir sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 7. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 9. lasix 40 mg tablet sig: one (1) tablet po once a day. 10. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. 11. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po bid (2 times a day). 12. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po qd (once a day). 13. captopril 25 mg tablet sig: four (4) tablet po tid (3 times a day). 14. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po bid (2 times a day). 15. insulin glargine 100 unit/ml solution sig: 35 units qpm subcutaneous once a day. 16. sliding scale insulin please see attached sliding scale for regular insulin 17. outpatient lab work please check electrolytes within 3 days 18. outpatient speech/swallowing therapy can be evaluated for swallowing when ventilator is weaned and is tolerating passey muir valve discharge disposition: extended care facility: - discharge diagnosis: non st segment mi - disease respiratory failure, requiring intubation cardiogenic shock anemia congestive heart failure with ef of 35% diabetes type 2, now insulin dependent ventilator associated pneumonia discharge condition: fair discharge instructions: vent settings: ps 10, peep 5, fio2 of 40%. titrate blood pressure meds closely. the patient has a tendency to flash pulmonary edema if she becomes hypertensive. keep her ins and outs even and check her potassium in the next day since her captopril was recently increased. titrate glargine and sliding scale insulin carefully. the patient is a brittle diabetic with a tendency to both hypo and hyperglycemia. check blood sugars frequently. do not allow her to eat since she has failed her speech swallow evaluation. she was fitted for a passey muir valve and can use it once her respiratory status becomes stable. followup instructions: please see dr. on monday at 9:45 pm () on in , . if there are problems with the tracheostomy or the peg tube, call dr. . he is located at , , , phone: fax: procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy transfusion of packed cells diagnoses: acidosis subendocardial infarction, initial episode of care urinary tract infection, site not specified congestive heart failure, unspecified acute respiratory failure iatrogenic pneumothorax cardiogenic shock methicillin susceptible pneumonia due to staphylococcus aureus diabetes with ketoacidosis, type ii or unspecified type, uncontrolled 

Answer: The patient is high likely exposed to