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: past medical history: as above. meds at home: 1. atenolol 50 qd. 2. losartan 50 . 3. lasix 20 qd. 4. aspirin 325 qd. 5. zantac 150 . 6. prilosec 20 qd. 7. norvasc 10 qd. 8. zocor 10 qd. 9. synthroid 0.1 qd. 10.atarax prn. 11.motrin prn. 12.colace 100 . 13.atrovent mdi prn. 14.albuterol mdi prn. allergies: penicillin. social history: smoking as above and occasional alcohol. physical exam on admission: vitals - 97.4, 85, 162/94, 18, 94% on 2 liters. general - the patient was an elderly, pleasant female in no acute distress. pupils equally round and reactive to light. there was extensive subcu emphysema of the left eye and face, as well as the neck and chest. the trachea was midline. chest exam was limited by crepitus. there was no hyperresonance to percussion. there was ecchymosis of the left chest wall, and a 24 french chest tube. the site was without erythema. heart was regular rate and rhythm. abdomen was soft, nontender. there was slight increased firmness to the left midabdominal and subcostal area. no discrete masses. no organomegaly. back showed ecchymosis to the left flank. extremities - a right femoral central line was in place. there was no clubbing, cyanosis or edema, and there were palpable femoral, popliteal, dorsalis pedis and posterior tibial pulses bilaterally. rectal showed no mass and was guaiac negative. pertinent labs: the patient's white count was 14.5, crit 39.1, platelets 305, sodium 131, potassium 3.9, chloride 94, co2 29, bun 11, creatinine 0.5, glucose 114. - pt 12.9, ptt 22.9, inr 1.1. abg was 7.47, 41, 68, 31 and 5, 93% on 2 liters. chest x-ray showed extensive subcu emphysema, chest tube in place, and no residual pneumothorax, rib fractures. impression: the patient is a 70-year-old female with severe, underlying lung disease, status post left chest blunt trauma with rib fractures and pulmonary parenchymal injury leading to pneumothorax and persistent air leak. hospital course: the patient was admitted and had a chest x-ray which showed a small pneumomediastinum, chest tube, and posterior rib fractures 6 through 9 which were displaced, and extensive subcu air. summary of patient's procedures this admission: on , the patient went to the or for a left video-assisted thoracoscopic surgery with debridement of the broken rib spicules, as well as wedge resection of the damaged lung parenchyma. on , the patient was taken to the or for an acute abdomen and was found to have a gangrenous right colon. she underwent a right colectomy, end-ileostomy, and transverse colon mucous fistula. the small bowel was found to have patchy areas of ischemia. on , the patient was taken back to the or for a second-look laparotomy, and underwent small bowel resection and end-ileostomy. on , the patient was taken back for a third-look laparotomy and was found to have a bowel perforation x 2. she had further bowel resection with end-jejunostomy, resulting in a total bowel length of approximately 3'. on , the patient underwent percutaneous tracheostomy, and on , the patient underwent left ultrasound-guided thoracentesis. additionally, the patient had multiple monitoring lines placed this admission. hospital course by system - 1) central nervous system: the patient had no mental status changes during this admission. earlier in her acute hospital course, she required a morphine drip for pain control and intermittent ativan for sedation, as well as a propofol drip early-on. most recently, her pain has been managed with dilaudid prn, as well as a dilaudid pca. 2) cardiovascular: the patient had a septic physiology through her initial three laparotomies requiring swan-ganz catheter placement and monitoring with pressor management including levophed and vasopressin. the patient underwent an echo after the initial laparotomy to look for an embolic source; however, no clot was identified on the limited study, and her ejection fraction was 55%. on serial cardiac enzymes, the patient was found not to have any evidence of myocardial ischemia. at this time, the patient is hemodynamically stable and is receiving metoprolol for beta blockade at a dose of 25 mg . she is in sinus rhythm, and her blood pressure is 143/59. 3) respiratory: due to the patient's persistent air leak, she was taken by the thoracic service on the 10 for a vats procedure. the broken ends of the ribs were debrided which had punctured and damaged the lung parenchyma, resulting in a persistent air leak. this section was lung was resected. on postop day #1 from that, the patient was stable and was transferred to the floor, and her chest tube was dc'd. however, the patient developed respiratory distress and was reintubated on the , with an abg showing a pco2 of greater than 100, and a ph of 7.0. a new left chest tube was placed with a moderate egress of air. additionally, a left subclavian cordis was placed, a swan-ganz catheter, and a right femoral a-line was placed. resulting chest x-ray showed no pneumothorax. the patient then had an acute abdomen and was transferred to the general surgery service. her chest tube was kept in place to suction and was finally put to water-seal and then dc'd on the . the patient had multiple attempts at vent weaning, however failed spontaneous breathing trials, and this was felt to be multifactorial due to her underlying lung disease, as well as malnutrition, volume loss in her left thorax, and a residual pleural effusion on the left, as well as a pneumonia. the patient underwent percutaneous tracheostomy on the to facilitate pulmonary toilet, as well as weaning, and an ultrasound-guided left thoracentesis for 250 cc on the . this showed no organisms on gram stains, and no neutrophils, and grew nothing on culture. on , the patient had a sputum positive for klebsiella pneumoniae for which she was treated with a course of aztreonam and gentamycin double-antibiotic coverage. despite this, the patient has been persistently unable to tolerate weaning trials and is currently vent dependent on pressure support of 10 and peep of 5, with a rsbi of 55, and a pco2 of 55. 4) abdomen: after the patient's reintubation on the 11, the patient was found to be persistently hypotensive and acidotic requiring pressors, and a new abdominal finding of distention and tenderness was noted. a general surgery consult was obtained on the . at this point, the patient had a white count of 19.7 and a lactate of 1.6, and she was on a neo drip for blood pressure support. the patient was placed on broad-spectrum antibiotic coverage of vancomycin, levofloxacin and flagyl. a rigid sigmoidoscopy was done at the bedside which showed viable sigmoid mucosa. a kub showed a dilated colon. the patient was taken later that day on the to the or for an exploratory laparotomy where a gangrenous right colon was resected. there were several patchy areas of small bowel ischemia which were left alone initially, and the patient was given an end-ileostomy, a transverse colon mucous fistula, and was sent back to the icu for further resuscitation with a planned second-look laparotomy. at this time, the patient was on levophed for blood pressure support and was continued on broad-spectrum antibiotics. on the , the patient was taken to the or for a second-look where frankly necrotic small bowel was resected, and the end-ileostomy was refashioned. the transverse mucous fistula was left in place. at this time, the patient was also evaluated for sources of possible embolic phenomenon with an echo which did not show any mural thrombus. a vascular consult was also obtained, and the patient's ischemic bowel was felt likely due to a low-flow state. on the , the patient was started on tpn, and then on the 18 the patient had a desaturation episode. a cta was negative for a pe and did show a left upper lobe infiltrate. she was requiring more fluid, had a persistent acidosis, and was on increasing levophed and pressor requirements. fluconazole was added to the vanc, levo and flagyl. the levo was then dc'd and imipenem was started. the patient's white count was now 31.7, and on the the patient was taken to the or again and found to have two small bowel perforations which were resected, and the patient was given an end-jejunostomy with a resultant approximate 3' of small bowel remaining. the patient was persistently hypotensive and vasopressin was added to her pressor management. on the , due to refractory leukocytosis, an id consult was obtained, and recommendation was made to increase her fluconazole dose. tube feeds were also instituted at a trophic rate of 10 cc/h of half strength alimental tube feeds. following the third laparotomy, the patient gradually stabilized over the remainder of her hospital course, and her tube feeds were gradually advanced. her ostomies remained viable, and her abdominal exam improved. the lower portion of her lower wound separated and has been managed by wet-to-dry packings. most recently, it has required some debridement if some fibrinous exudate at the base of the wound. today, the patient's abdomen is soft. her ostomies, that is her jejunostomy and mucous fistula, are pink and viable. her lower wound separation is granulating laterally with a fibrinous exudate at the base with visible fascial sutures at the base of the wound. this will be managed with wet-to-dry dressing changes. 5) gu and renal: the patient's renal function remained stable throughout all of her septic complications. she had a foley in place throughout this hospitalization and maintained good urine output. following her final laparotomy, the patient did require diuresis to facilitate weaning of her ventilator. however, this has not helped with the vent weaning. the patient is currently on lasix 40 per ng tube . 6) infectious disease: the patient has had multiple infectious complications during this complicated admission. her swab from the laparotomy on the 15 grew out yeast and klebsiella. additionally, she had klebsiella grown out of her sputum on the 13, and yeast of the sputum on the 16, as well as mrsa. on the 18, an additional sputum culture grew out klebsiella, and her urine from the 18 grew out yeast. wound culture from the 19 and 23 grew out yeast. these were all sensitive to fluconazole. currently, the patient is on aztreonam day 11 and gentamicin day 12 of a 14-day course for a pseudomonas and klebsiella culture that was grown out from her sputum on the . additionally, she is on a fluconazole course also to be completed for a 14-day course. the patient has remained afebrile over the last week, and currently her refractory leukocytosis is at 17.1. 7) hematology: the patient has had rare transfusion requirements after her laparotomies. additionally, after her initial laparotomy she required a platelet transfusion for a thrombocytopenia, and her heparin was also held at that point, and a hit antibody was sent which ultimately came back negative, and she was restarted on heparin for dvt prophylaxis. currently, her crit is 31.2 and her platelets 249. her inr is 1.1, and ptt is 27.2. 8) fen: the patient has become tpn dependent essentially. she is also receiving tube feeds at a rate of 60 an hour using impact with fiber 3/4 strength, and this is felt not to be adequately absorbed with her short-gut syndrome. so, she is also on essentially goal tpn calories. she also has hyponatremia of 129. her k is 4.6, chloride 94, mag 1.8, phos 2.7, calcium 8.4. the hyponatremia is being treated with decreasing her free-water intake. 9) endocrine: the patient has been managed with a regular insulin sliding scale. 10) prophylaxis: the patient has received gi prophylaxis using a proton pump inhibitor. currently, she is on lansoprazole 30 per ng tube qd. additionally, she is receiving heparin in her tpn, and has pneumoboots in place for dvt prophylaxis. tubes, lines and drains: currently, the patient has a foley, a transpyloric feeding tube, a tracheostomy tube, a picc line, and a-line. discharge diagnoses: 1. multiple left rib fractures. 2. left pneumothorax. 3. status post left video-assisted thoracic surgery (vats) with debridement of rib fragments and wide-resection of injured lung segment. 4. infarcted small bowel and right colon. 5. status post laparotomy with right colectomy, end-ileostomy, and transverse colon mucous fistula. 6. second-look laparotomy with small bowel resection and redo end-ileostomy. 7. third-look laparotomy for small bowel perforation x 2, status post further small bowel resection, end-jejunostomy. 8. short-gut syndrome with total parenteral nutrition dependence. 9. klebsiella and pseudomonas pneumoniae. 10.peritoneal fluid yeast positive culture. 11.ventilator dependence, status post tracheostomy. 12.coronary artery disease, status post myocardial infarction with percutaneous transluminal coronary angioplasty and stent in . 13.chronic obstructive pulmonary disease. 14.hypercholesterolemia. 15.hypothyroidism. 16.hyponatremia. 17.leukocytosis. 18.midline laparotomy wound infection, status post wet-to-dry dressing changes . discharge medications: 1. tincture of opium per ng tube qid. 2. sodium chloride 1 tablet tid. 3. lansoprazole 30 per ng tube qd. 4. dilaudid prn. 5. lasix 40 per ng tube . 6. levothyroxine 100 per ng tube qd. 7. metoprolol 25 per ng tube . 8. fluconazole 400 per ng tube qd. 9. albuterol and atrovent nebs per tracheostomy prn. 10.gentamicin 400 mg iv qd, day 12 of 14. 11.aztreonam 1 gm iv q 8, day 11 of 14. 12.regular insulin sliding scale. discharge plan: discharge to pending bed availability, and further addendums will be dictated in a separate report. , m.d. dictated by: medquist36 procedure: other partial resection of small intestine other partial resection of small intestine thoracentesis other and unspecified partial excision of large intestine exploratory laparotomy exploratory laparotomy exploratory laparotomy temporary tracheostomy transpleural thoracoscopy other partial ostectomy, scapula, clavicle, and thorax [ribs and sternum] other local excision or destruction of lesion or tissue of lung other permanent ileostomy closure of laceration of lung injection of anesthetic into peripheral nerve for analgesia proctostomy diagnoses: perforation of intestine traumatic pneumothorax without mention of open wound into thorax acute vascular insufficiency of intestine pneumonia due to klebsiella pneumoniae closed fracture of multiple ribs, unspecified interstitial emphysema laceration of lung without mention of open wound into thorax 

Answer: The patient is high likely exposed to