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: sulfa (sulfonamide antibiotics) / bactrim attending: chief complaint: weakness and lethargy major surgical or invasive procedure: picc line placed rue wound debridement of lle ulcers history of present illness: in brief, is a 76 yo f who has complex infectious history who presents to for 1 week of progressive weakness and lethargy. in summary of her infectious history, she had a cabg in c/b le cellulitis at site of venous harvest (linezolid), dehiscense of her sternal wound s/p pec flap , readmitted for non-healing sternal wound s/p debridement, cultures grew torulopsis and cons, discharged on 6 weeks vanco/micafungin showed clinical improvement, she lost iv access and vanco switched to linezolid/fluconazole. readmitted for sternal plate removal and wound closure, bone cultures grew c.albicans, she was also found to have uti treated with cefepime, discharged home with daptomycin for cons cx in . dapto switched to linezolid on for rising eos and finally discontinued on . also of note, she was recently treated with cipro for uti and then augmentin for another uti at . she has a complex medical hsitory as well which is significant for a.fib on coumadin, type ii dm, primary biliary cirrhosis. . patient is unable to give a good history as she is falls asleep frequently during examination but per report: she was sent to the ed today from for worsening lethargy. she reports progressive weakness over several weeks, usually gets around fine with a wheelchair but over past week has been requiring a motorchair to get around, she has also described shortness of breath and more rapid breathign. in the ed, initial vs 97.2 58-87 105/66-121/57 18 97-100% on ra. significant labs included cr of 1.5, hct 23.4, inr 3.3. bicarb was 10 with gap of 22. lactate was 2.0. u/a showed trace leuks, 2wbcs. she was guaiac negative. . currently, the patient is very groggy and appears chronically ill. she frequently falls asleep during questioning and she is difficult to understand as her voice is soft and appears labored. when she is more aroused she is oriented x 3, mentatintg well and is able to relay her history. . on ros, the patient reports losing 70 lbs since her cabg in , + sob x weeks, no cp, occasional n/v, recent profuse diarrhea - xs per day, last episode was monday. she denies fevers/chills and denies abdominal pain. past medical history: 1. right total knee and hip replacements 2. left superficial temporal artery biopsy 3. coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery followed by plating x 5 in 4. sternal wound separation s/p readvancement of pectoralis flaps and reclosure of sternal wound 5. chronic atrial fibrillation on coumadin, diagnosed 6. stable primary biliary cirrhosis 7. type ii diabetes 8. hypothyroidism 9. polymyalgia rheumatica diagnosed , on prednisone 10. hypercholesterolemia 11. osteoarthritis 12. vulvar cancer s/p vulvectomy at (no chemo or radiation) 13. urinary incontinence s/p vulvectomy 14. h/o nephrolithiasis 15. chronic lower extremity edema r/t lymphedema 16. h/o urosepsis 17. arthritis left knee social history: prior to her recent hospital stays, the patient had lived in , ma with her husband; former smoker - quit at age 40, no illicits; drinks etoh socially. she was the director of nursing at on staff for 30 years family history: ms. sister died last year at age 71, s/p cabg at age 39, redo cabg at age 49, and peripheral bypass. her father had a myocardial infarction at age 50 and died at age 76 from a ruptured abdominal aortic aneurysm. physical exam: general: nad, lethargic but arousable, chronically ill-appearing, obese, deeply breathing, trails off when talking and frequently falls asleep heent: perrl, pale conjunctiva, op clear, dry mm neck: supple, no jvd, no lad heart: rrr w/ frequent premature beats, sustained s1, no mrg, chest: sternal wound is bandaged, appears to be healing well lungs: cta bilat, no r/rh/wh; deeply breathing abdomen: obese, soft/nt/nd, no rebound/guarding, +bs extremities: obese legs, distal wounds are bandaged, pressure ulcers on posterior legs are very tender, feet are warm. she has a foul smelling, pressure ulcer on posterior left leg: there is central necrosis with non-viable tissues surrounded by red, swollen skin but without evidence of frank cellulitis. there is also a larger, foul smelling pressure ulcer over left lateral thigh with central non-viable-tissues surrounded by swollen/red skin but does not appear to be frank cellulitis. her hands are cold bilaterally and her fingers appear mottled. she has multiple areas of frank skin break down over arms and under breasts. neuro: aox3, lethargic, cns ii-xii grossly intact, moving all extremities pertinent results: admission labs: 08:10pm blood wbc-14.9* rbc-2.50*# hgb-7.2*# hct-23.4* mcv-93 mch-28.7 mchc-30.8* rdw-17.0* plt ct-508* 08:10pm blood neuts-78.9* lymphs-14.0* monos-2.5 eos-3.8 baso-0.7 08:10pm blood pt-33.0* ptt-37.1* inr(pt)-3.3* 08:10pm blood ret man-2.1* 08:10pm blood glucose-113* urean-34* creat-1.5* na-143 k-3.9 cl-111* hco3-10* angap-26* 08:10pm blood alt-4 ast-9 ld(ldh)-134 ck(cpk)-35 alkphos-136* totbili-0.1 08:10pm blood ck-mb-3 ctropnt-0.06* probnp-2799* 08:10pm blood albumin-2.4* calcium-9.0 phos-3.3 mg-1.9 08:10pm blood d-dimer-503* 08:10pm blood tsh-30* 08:16pm blood lactate-2.0 lethargy work up: 08:10pm blood wbc-14.9* rbc-2.50*# hgb-7.2*# hct-23.4* mcv-93 mch-28.7 mchc-30.8* rdw-17.0* plt ct-508* 08:10pm blood ret man-2.1* 08:10pm blood glucose-113* urean-34* creat-1.5* na-143 k-3.9 cl-111* hco3-10* angap-26* 08:10pm blood albumin-2.4* calcium-9.0 phos-3.3 mg-1.9 12:51pm blood caltibc-122* vitb12-1275* folate-4.7 ferritn-1494* trf-94* 08:10pm blood tsh-30* 05:30am blood free t4-0.90* 04:51am blood freeca-1.38* anion gap work up: 11:46am blood parathyroid hormone related protein-wnl 12:51pm blood beta-hydroxybutyrate-negative 04:51am blood lactate-1.0 08:10pm blood asa-neg acetmnp-neg 04:00pm blood pep-polyclonal 12:51pm blood acetone-negative osmolal-303 09:35pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-tr 09:35pm urine hours-random urean-453 creat-89 na-32 k-55 cl-less than 11:20am urine hours-random urean-327 creat-54 na-90 k-32 cl-63 hco3-less than 09:35pm urine osmolal-433 07:10pm urine u-pep-multiple p ife-no monoclo 05:54pm urine organic acid-pnd anion gap trend: (received bicarb after work up negative and ag unchanged) 08:10pm blood glucose-113* urean-34* creat-1.5* na-143 k-3.9 cl-111* hco3-10* angap-26* 06:38am blood glucose-77 urean-19 creat-1.1 na-145 k-3.9 cl-117* hco3-11* angap-21* 05:16am blood urean-12 creat-1.1 na-147* k-4.2 cl-118* hco3-14* angap-19 05:57am blood glucose-115* urean-11 creat-1.0 na-137 k-3.7 cl-108 hco3-21* angap-12 05:45am blood glucose-93 urean-8 creat-1.2* na-139 k-3.8 cl-109* hco3-18* angap-16 4:23 pm swab source: left medial lower leg. add-on from (fax) for gram stain @1014. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final ): pseudomonas aeruginosa. rare growth. piperacillin/tazobactam sensitivity testing performed by . staphylococcus, coagulase negative. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | amikacin-------------- 16 s cefepime-------------- 8 s ceftazidime----------- 4 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem------------- =>16 r piperacillin/tazo----- s tobramycin------------ =>16 r c.diff toxin negative c.diff pcr negative bcx negative x2 bcx ngtd x2 ucx negative x2 discharge labs: ******************** reports: cxr : pa and lateral views of the chest: cardiac silhouette is minimally enlarged, though unchanged. mediastinal and hilar contours are also unchanged. there is no pleural effusion or pneumothorax. a right peripherally inserted central catheter has been removed. cta : no pulmonary embolism. no acute intrathoracic process cxr : findings: in comparison with the study of , there is little change and no evidence of acute pneumonia. central catheter remains in place ulcer biopsies pending: brief hospital course: is a 76 yo f who has complex infectious history including a cabg with post-op course c/b sternal wound infections. she has been living in a nursing facility and has experienced recurrent pressure ulcer infections and utis who presents to for 1 week of progressive weakness and lethargy. # lethargy: lethargy is most likely multifactorial from infectious process, anemia, opiate use and compounded by metabolic disturbance and increased work of breathing. for infection, she was started on vancomycin and zosyn, after wound culture grew pseudomonas she was narrowed to zosyn only. the zosyn was continued for nearly two weeks when it was discontinued because of worsening diarrhea and without a change in her clinical status. for her anemia she was transfused 1 unit prbcs with improvement in her metabolic alkalosis (see below) but without a sustained improvement in her crit. her metabolic disturbances were worked up as below and her clinical status did not improve much other than correcting her anion gap with bicarb supplementation. hypothyroidism was considered and tsh, ft4 were drawn which were compatable with hypothyroidism and her synthroid was increased to 250mcg/day, again without significant improvement in her clinical status. #acid/base distubrance: when she was admitted she had a profound anion gap with a hco3 of 10; her ph of 7.38 suggested there were 3 processes occuring. she had an anion-gap metabolic acidosis (ag=26), when corrected for ag it appears she had a superimposed non-gap metabolic acidosis. in addition, the patient's co2 was too low for a respiratory compensation and instead suggested a primary respiratory alkalosis in addition to respiratory compensation. serum tox was negative for salicylates, patient was a nurse in her career and she was transferred from hospital: methanol, ethanol or paraldehyde toxicity would be extremeley unlikely, she does not take inh and in addition her gap remained open >1week and it would have been expected that any ingestion would have cleared in that time. her urine was negative for ketones, blood acetone and beta-hydroxybutyrate were negative as well. bun was 34, lactate was 1.0 and so uremia/lactic acidosis not cause of her gap either. there was no serum osmolar gap and her urine lytes suggested she was not renally wasting bicarb (ubicarb <1). she was trasfused 1 unit prbcs and started on vanc/zosyn for sepsis criteria (le ulcers infectios source) and her primary respiratory alkalosis resolved. she did have diarrhea on presentation which after giviing ivf and loperamide/lomotil her primary non-gap resolved as well. renal was consulted for ongoing ag acidosis of unclear etiology though the anions remained elusive, she was repleted with 1.5amps bicarb in 1 unit d5w x6l and her gap closed with bicarbs returning to low 20s. when bicarb supplementation was stopped her gap began opening again. currently the source of her unmeasured anions is unclear, urine organic acids are pending. # leukocytosis: patient had multiple sources for infections and a complex infectious history. during this hospitalization the most likely source of infection waslikely pressure ulcers on lle and left later thigh. urinalysis was negative, bcx negative, c.diff toxin negative x2 and c.diff pcr negative, cxr and pe did not suggest pna and sternal wound appears to be improved from prior. lle ulcer grew rare pseudomonas and so vancomycin discontinued and zosyn continued. zosyn was continued for nearly 2 weeks without improvement in her clinical status and without a downtrending wbc count (remained around ). wound was consulted for wound care and plastics followed patient for lle wound debridement. # anemia: patient presented with an 8 pt hct drop since , though her baseline was uncertain. she did have a primary resp alkalosis on admission with subjective sob. she was transfused 1 unit prbcs with improvement in primary resp alk but continued deep breathing (compensation for met acid). her iron studies were consistent with anemia of chronic disease and she had a reticulocyte count which was not appropriate for her level of anemia. she was continued on iron and mvi. # : patient admitted with an elevated creatinine of 1.5. her baseline was unclear as there are multiple creatinines in omr >1.5 but it appears her last admission creatinine 0.8-1.1. per opat notes her creatinine has been uptitrating at . bun:cr >20 but urine lytes also suggeted intrinsic kidney injury and so she likely had an aspect of pre-renal etiology in addition to intrinsic . lasix were held and ivf given and she showed improvement in her renal function to a creatinine of 0.9. chronic stable conditions: # afib: during admission she was in sinus with frequent premature beats. inr supratherapeutic at 3.3. coumadin was held and she remained at supratherapeutic levels for 1 week until vitamin k was given for wound debridement. metoprolol was continued but because she remained hypotensive throughout admission it was largely held. # cad s/p cabg: bnp elevated and ekg with twf laterally on admission. continued aspirin as low probability anion-gap is salicylate toxicity (salicylates negative on admission). # chronic sternal wound: continued fluconazole (renally dosed). plastics debrided wound and placed a sternal wound vac which was continued for *** # dm: hiss, given reports of recent lows at # pbc: continued ursodiol # hypothyroidism: part of lethargy work up she was found to have a tsh of 30 and a ft4 of 0.9. synthroid was increased from 200mcg to 250mcg daily # gerd: continued omeprazole # depression: continued wellbutrin, remeron . # diarrhea: chronic on admission, c.diff toxin and pcr negative. thought to be antibiotic related as it worsened with zosyn and improved after zosyn discontinued. loperamide and lomotil given for symptomatic relief. # end of life events: pt was transferred to micu on . she was started on norepinephrine, and then phenylephrine for refractory hypotension. a-line and central line was placed. ng tube was placed for nutrition. pt had increased requirement for pressor support. she continued to decline despite broad antibiotics, including vancomycin iv, metronidazole, vancomycin po, meropenem, and micafungin and supportive care including two pressors. family meeting was held on , and given her acute decompensation despite aggressive managment from , the consensus decision was made to transition her to cmo. the patient's husband, dr. , made this decision in concert with the medical team as he felt it best reflected the patient's wishes. she was subsequently transitioned to comfort care. pt deceased at 18:09 on . family was present at that time. autopsy was offered and dr. accepted. nurse and her family were all sincerely thanked for her numerous and significant contributions to our hospital and informed that we will mourn her loss as well. medications on admission: medications (according to records) oxycodone 5 mg q3h prn zofran 4 mg po prn tramadol 50 mg q8h lasix 20 mg qday wellbutrin sr 100 mg qam compazine 10 mg qam colace ferrous sulfate 325 mg qday lvtx 200 mcg qday aspirin 81 mg qday ursodiol 300 mg dulcolax 10 mg qam remeron 7.5 mg hs tylenol 1g q8h fluconazole 400 mg qday metoprolol 25 mg qday hiss coumadin given 0.5 mg on and to be given discharge medications: none discharge disposition: expired discharge diagnosis: respiratory distress, sepsis, altered mental status discharge condition: expired discharge instructions: none followup instructions: none procedure: enteral infusion of concentrated nutritional substances arterial catheterization other skin graft to other sites nonexcisional debridement of wound, infection or burn central venous catheter placement with guidance diagnoses: acidosis anemia, unspecified polymyalgia rheumatica pure hypercholesterolemia other postoperative infection long-term (current) use of steroids diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status personal history of tobacco use depressive disorder, not elsewhere classified surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation long-term (current) use of insulin pressure ulcer, other site long-term (current) use of anticoagulants osteoarthrosis, unspecified whether generalized or localized, site unspecified pressure ulcer, buttock diarrhea encounter for palliative care do not resuscitate status hyperosmolality and/or hypernatremia other and unspecified coagulation defects leukocytosis, unspecified hypercalcemia pseudomonas infection in conditions classified elsewhere and of unspecified site candidiasis of skin and nails mixed acid-base balance disorder pressure ulcer, stage ii biliary cirrhosis pressure ulcer, stage iii other lymphedema malnutrition of moderate degree shock, unspecified disruption of wound, unspecified full incontinence of feces encounter for change or removal of surgical wound dressing 

Answer: The patient is high likely exposed to