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: history of present illness: mrs. is a 54 year old female with a past medical history significant for hypertension for which she takes norvasc who was involved in a motor vehicle accident in . she was a pedestrian struck by an suv that pinned her under the car. this involved a relatively prolonged extrication. she had a low coma score on scene and was hemodynamically unstable with blood pressures 80/palpable and heart rate of 130. she was intubated by and brought in as a trauma plus activation. past medical history: 1. hypertension. medications at home: 1. norvasc 5 mg q. day. allergies: no known drug allergies. past surgical history: unknown. family history: noncontributory. social history: she is married and has at least one daughter. otherwise, high functioning at baseline. she does not smoke; has no significant alcohol intake or history. has no history of intravenous drug abuse. review of systems: she was otherwise normal and healthy prior to this event. physical examination: vital signs on presentation were: she was hypothermic at 95.9 f., rectally; her heart rate was 130; blood pressure was 60/palp; she was breathing 12 on a vent with a saturation of 100%. she had coma score of 3t on arrival. her heent examination was normocephalic, atraumatic. pupils equally round and reactive to light and accommodation. they were 3 to 2 and sluggish. her mid face was stable. her oropharynx was normal with an endotracheal tube noted at 22 cm at the lip. her neck was without crepitus. her trachea was midline. she had no obvious scalp deformities or laceration. her clavicles were without deformity. her chest was decreased on the left side with obvious subcutaneous emphysema and crepitus. her right chest was somewhat clear to auscultation. her abdomen is obese, slightly distended. there was no obvious ecchymosis or pulsatile mass. her pelvis was unstable. her both lower extremities were externally rotated. there was no step off deformity of either of her extremities. her talus revealed no evidence of step off. there was ecchymoses in the flanks bilaterally. we could not assess tenderness as the patient was intubated and sedated. her cervical spine was without step off or deformity as well. a foley catheter was placed after rectal examination revealed normal tone, foley catheter was draining slightly red tinged urine. due to the patient's profound hemodynamic instability, the patient received a left chest tube and left tube thoracostomy for presumptive hemopneumothorax with possible tension. a fast examination of the abdomen was otherwise normal. she underwent a diagnostic peritoneal lavage in the supraumbilical position to avoid any possible pelvic hematoma that may be tracking to the anterior sheath. this was negative grossly. it was determined that due to the unstable nature of her pelvic fracture that her hemodynamic instability was likely secondary to an ongoing pelvic bleeding source. she received a right tube thoracostomy as well empirically due to the fact that she was profoundly hemodynamically unstable. she was getting uncross matched o negative blood products in the bay as part of her resuscitation with wide open fluids, bilateral cordis subclavian lines were additionally placed during her trauma resuscitation. once all lines and tubes were secured and the patient's hemodynamics were "relatively stable", she was emergently taken to the interventional radiology suite where the patient, under the care of dr. of the interventional radiology department, underwent a pelvic angiography and embolization of a branch of the left internal iliac artery. she required ongoing cryoprecipitate fresh frozen plasma and packed red blood cells in transfusions and arterial blood gases were sent serially from the right femoral sheath which was left in place by the interventional radiology services. her base deficit was initially as high as minus 15. this was declining during her resuscitation for several hours of admission. she was on a small dose of neo-synephrine for tone as we were actively and aggressively bolusing her fluids at wide open crystalloid going and were given all transfusions, crystalloid or packed cells or fresh frozen plasma through a level 1 transfuser. once the patient's pelvis had been previously wrapped and stabilized in the trauma bay, she was again emergently taken to the angiography suite where the embolization of the branch of the left internal iliac artery was investigated and stopped. she thereafter was then transferred immediately to the trauma intensive care unit unit, intubated, hemodynamically unstable. over the next several days, the patient required several units of blood products and fresh frozen plasma. she had high volume requirements. she did not require pressors thereafter. she was being maintained on sedation, however, off sedation, she intermittently moved all four extremities, however, was not following commands. it should be noted that post pelvic angiography just prior to her transfer to the intensive care unit she did receive a ct scan of the head, neck and abdomen. the ct scan of the head was unremarkable showing no evidence of skull fracture or parenchymal injury. a ct scan of the cervical spine was also negative. her ct scan chest showed no evidence of large vessel injury. she had multiple left sided rib fractures and hemopneumothorax with bilateral tube thoracostomy noted. she had no evidence of esophageal injury. she had a very small pericardial effusion with the helmsfield units on this effusion being consistent with physiologic fluid. she had a small grade i right posterior hepatic lobe contusion with no evidence of hematoma or extravasation. there was evidence of a right perinephric and adrenal hematoma. there was a small amount of hemoperitoneum. there was no obvious splenic injury. the duodenum and pancreas were unremarkable. she did have events of retroperitoneal hemorrhage, was not actively extravasating on her ct scan of the abdomen post angio and embolization. again, as re-iterated above, her next several days in the intensive care unit were somewhat guarded. she was massively resuscitated. she developed adult respiratory distress syndrome and required high ventilatory peeps and she had lung protective ventilation to utilize with her high peep, low tidal volume and persistent hypercapnia being utilized in her management strategy. please note that the remainder of her hospital course will be summarized by system: 1. neurologic: the patient had no evidence of intracranial injury. she was given a fentanyl drip and p.r.n. ativan as well as propofol for sedation. intermittently her neurologic examination revealed that she is moving all four extremities. this was continued until time of her extubation several weeks after her admission. for her cervical spine she could not receive an mri, therefore her collar was kept in place until she was extubated, after which time she was clinically cleared. 2. pulmonary status: the patient had adult respiratory distress syndrome which resolved after several days. she had a ventilator associated pneumonia secondary to enterobacter aerogenes for which she received a total of two weeks of zosyn. her sputum thereafter grew out some methicillin resistant staphylococcus aureus which was likely colonized. her chest x-ray showed bibasilar infiltrates, left greater than right, with a small left pleural effusion. over several days and weeks, her chest tubes began to drain less. they were removed without event. she had had a previous second left tube thoracostomy placed at the time of her post initial resuscitation secondary to the fact that the initial tube thoracostomy on the left side was somewhat low and skiving the diaphragm and the tip of the tube was abutting the ge junction. at the time of dismissal, both chest tubes were out. she is otherwise saturating well on room air with 92 to 94% saturation. her last chest x-ray after time of picc line placement showed that she had a persistent small left lower lobe consolidation with an associated left pleural effusion that was stable in appearance. her ventilator associated pneumonia had been adequately treated. her adult respiratory distress syndrome had fully resolved. she is now receiving incentive spirometry, chest physiotherapy and was out of bed to chair with the physical therapy service. she was utilizing albuterol as needed for any expiratory wheezing. 3. cardiovascular: the patient initially was profoundly hemodynamically unstable and was stabilized with volume resuscitation and once control of her bleeding was obtained angiographically. it should be noted that her transfusion requirements stopped immediately after her external fixation of her pelvis which was performed four days into her hospitalization by dr. . at the time of this dismissal, she was receiving lopressor for blood pressure and heart rate control. her norvasc had not been resumed from her outpatient regimen. this can be reassessed in the rehabilitation services. 4. gastrointestinal: the patient had had an esophagram performed within three days of admission secondary to worry that she may have had partial esophageal injury secondary to the lowly placed left tube thoracostomy that was initially initiated in the initial trauma resuscitation. her upper gi and barium swallow showed no evidence of esophageal injury. she was maintained and supported on tube feeds for several weeks. post extubation and while on the floor, the patient's tube feedings were continued until which time her mental status improved. thereafter she was evaluated by speech pathology which showed that her voice was somewhat weak. she did have evidence of some clinical aspiration of thin liquids. after consultation with the otolaryngology service and determination that she had some mild focal paresis that would likely resolve over time, the patient was recommended to have a nectar thickened liquid diet with full solids as tolerated and be sitting upright with her meals. she should not drink thin liquids at this time. she was on a ppi for acid reflux protection as well as to protect her vocal cords, which was recommended by the orl consultation service. she was having normal bowel movements. she had had some intermittent loose bowel movements which were otherwise clostridium difficile negative during this hospitalization. 5. hematology / infectious disease: the patient required multiple units of transfusion of packed red blood cells as well as fresh frozen plasma. she did receive at least one transfusion of cryoprecipitate during this hospitalization. she was currently being anti-coagulated and protected with lovenox. she will be transitioned off of lovenox to coumadin once her inr reaches the level of approximately 2.0. she is at exceedingly high risk for development of deep venous thrombosis secondary to her multiple pelvic fractures and the fact that she had had an external fixator device placed on her pelvis for stabilization as well as sacroiliac joint screws. she should be checked with serial inrs as an outpatient in rehabilitation and once she has reached the therapeutic regimen, her lovenox should be discontinued. she will continue on the coumadin as long as she is minimally ambulatory while in rehabilitation. 6. infectious disease: the patient did have a course of zosyn times two weeks for a ventilator associated pneumonia secondary to enterobacter aerogenes. she did have a small left lower lobe consolidation, and possible pneumonia which was stable and relatively improved from her initial films early in her hospital course. at the current times, she was not spiking any temperatures and was not on any current antibiotics. she had no other outstanding infectious issues pending. she is a carrier of methicillin resistant staphylococcus aureus and we feel that her sputum culture which has methicillin resistant staphylococcus aureus is not a pathogen but merely a colonizing . she did have enterococcus which was vancomycin sensitive as well as ampicillin sensitive and grew out in her blood from blood cultures on . surveillance blood cultures thereafter were otherwise negative. this was thought to be due possibly secondary to a subclavian line which was ultimately removed. the patient currently has a picc line inserted and received at least ten more days of vancomycin, one gram intravenously q. 12 with levels of peak and trough to be checked as an outpatient, goal being between 30 and 40 with trough values less than 15. this was done secondary to her two out of four blood cultures positive with enterococcus bacteremia and the risk of feeding her external fixator device. there was no obvious cellulitis or drainage from her external fixator device at time of dismissal. 5. genitourinary / renal: she did have a foley catheter in place. she had no positive urine cultures in the last several weeks. she was making excellent urine. it was quite diluted in nature. she had had a ct urogram performed during her hospitalization for intermittent hematuria which showed no evidence of bladder injury. the foley catheter can be removed whenever deemed appropriate by rehabilitation services. 6. tubes / drains: she does have a picc line inserted in her antecub. this was done on for her vancomycin. a left subclavian had been removed on , once picc line insertion was confirmed. she did not have any other drains or indwelling catheters. 7. activity and weight bearing status: per the orthopedic service she will remain non-weight bearing on the right lower extremity and full weight bearing on the left lower extremity. she should only be allowed to pivot and transfer from bed to chair with physical therapy assistance. this will continue for another eight weeks per dr. . the patient was otherwise tolerating a diet as described above with assistance and was deemed appropriate and stable for dismissal to rehabilitation on . discharge medications: 1. albuterol one to two puffs q. six p.r.n. 2. tylenol 325 mg p.o. q. four to six p.r.n. 3. bisacodyl 10 mg suppositories per rectum q. h.s. p.r.n. 4. miconazole powder nitrate one application as needed to any intertrigonal folds for possible intertriginal candidiasis. 5. clonidine patch 0.1 mg q. 24 hours one application q. week every tuesday. 6. colace 100 mg p.o. twice a day for bowel regimen. 7. lopressor 100 mg tablet, one tablet p.o. twice a day. 8. lovenox 30 mg subcutaneously q. 12 to be continued until her inr is therapeutic. 9. additionally, sliding scale insulin as directed. 10. coumadin 10 mg p.o. q. day with an inr check to be completed every other day until her inr is therapeutic at which time her lovenox will be stopped. 11. vancomycin one gram intravenous q. 12. peak and trough values to be checked as described above, to be continued for an additional seven days. 12. protonix 40 mg p.o. q. day to be continued indefinitely. discharge diagnoses: 1. status post motor vehicle crash pedestrian versus car with long extrication and pinning. 2. closed head injury with concussion; no other parenchymal injury noted by ct scan times two. 3. profound hemodynamic instability. 4. open pelvic fracture. 5. bilateral acetabular fractures. 6. bilateral pubic rami fractures. 7. open pubic symphysis with 3 cm of diastasis. 8. multiple left sided rib fractures with a flail segment. 9. bilateral scapular fractures. 10. left hemopneumothorax with subcutaneous emphysema status post bilateral tube thoracostomies and a second left chest tube placement later on her first day of admission. 11. grade i right hepatic lobe contusion which was stable on repeat ct scan. 12. right perinephric hematoma. 13. right adrenal hematoma, stable on follow-up ct scan of the abdomen. 14. small amount of hemoperitoneum; no abdominal exploration required. 15. negative diagnostic peritoneal lavage. 16. l1 and l2 transverse process fractures. 17. l4 spinous process fracture. 18. l5 posterior element fracture extending into the facet. 19. status post urgent angiography and embolization of the left of the left internal iliac artery secondary to active extravasation and exsanguinating hemorrhage. 20. respiratory failure prolonged intubation with ventilator associated pneumonia secondary to enterobacter aerogenes sensitive to piperacillin and tazobactam; status post treatment. 21. status post acute respiratory distress syndrome, resolved. 22. methicillin resistant staphylococcus aureus carrier status. 23. enterococcus bacteremia, with two out of four blood cultures positive on . follow-up blood cultures negative to date; thought to be secondary to possible line sepsis. 24. evidence of aspiration of thin liquids as noted by bedside speech pathology evaluation and swallow by otolaryngology and nasopharyngeal endoscopy with vocal cord evaluation. major surgical invasive procedures: 1. emergent bilateral tube thoracostomy; bilateral subclavian cordis line placement . 2. status post supraumbilical diagnostic peritoneal lavage . 3. status post emergent pelvic angiography and embolization . 4. status post pelvic stabilization with pelvic wrap . 5. status post external fixation sacroiliac joint screw placement on . 6. status post picc line insertion for intravenous antibiotics. discharge instructions: the patient and family are both aware of all diagnoses and treatment plans. the patient treatment frequencies as outpatient will include to receive twice a day pin care using a 50/50 solution of peroxide and normal saline. she should continue to place a xeroform dressing and dry gauze to her anterior abdominal wall where she suffered an abrasion and superficial burns secondary to the gas tank of the suv that pinned her. she should get sterile picc line nursing care per protocol. she should get a vancomycin peak and trough within several days of dismissal with a goal peak of 30 to 40 and a trough value of less than 15. additionally, she should get coumadin dosed at 10 mg p.o. q. day with a goal inr of 2.0 to stop her lovenox once therapeutic. her diet will include a soft regular house diet as tolerated with nectar thickened liquids. she should sit upright when eating. follow-up instructions: 1. her recommended follow-up is to see dr. in two to four weeks from time of dismissal. call . 2. she should return to the trauma clinic in three to four weeks from time of dismissal to see how she is progressing, to listen to her lungs and to insure that her left lower lobe consolidation and small effusion has not expanded. 3. she may require a follow-up chest x-ray as an outpatient. 4. she should follow-up with otolaryngology in approximately two to four weeks for further evaluation of her vocal cord function and recovery by calling . 5. the patient's weight bearing status on dismissal: she can participate in transfers out of bed to chair with pivot. she is non weight bearing to the right lower extremity and full weight bearing to the left lower extremity for the next eight weeks. 6. her upper extremities are full weight bearing as tolerated. at time of dismissal, she was alert and oriented and following commands within all four extremities, tolerating a diet as described above and participating in physical therapy as noted. , m.d. dictated by: medquist36 d: 17:41 t: 18:12 job#: procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances arteriography of other intra-abdominal arteries other endovascular procedures on other vessels transfusion of packed cells application of external fixator device, other bones transfusion of other serum peritoneal lavage diagnoses: pneumonia due to other gram-negative bacteria traumatic pneumohemothorax without mention of open wound into thorax other shock without mention of trauma bacteremia concussion with loss of consciousness of unspecified duration closed fracture of multiple ribs, unspecified open fracture of pubis open fracture of acetabulum 

Answer: The patient is high likely exposed to