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 / morphine / demerol attending: chief complaint: chest pain major surgical or invasive procedure: bronchoscopy history of present illness: 63 y/o man with pmh significant for traumatic brain injury following fall in ; trach in and peg secondary to failure to thrive; siezure disorder admitted from osh for picc placement and further eval of the above. pt was in his usual state of health at his nursing home until at which time he developed a temperature of 102.7 and oxygen saturation of 79 percent on room air. he was sent to the for futher care. there, a cxr showed left lower lobe infiltrate and 5 posterior left sided rib fracutres. by report, pt had recently fallen backward twice at the nursing home. in addition, he was being treated with clindamycin (since ) and levofloxacin () for a question of pneumonia. at , pt was admitted for treatment of his pneumonia and hypernatremia. initial vital signs included temperature of 102.2, blood pressure 100/68, oxygen saturation 98% on nonrebreather, and respiratory rate of 36. labs were significant for a wbc count of 14.9 and a sodium of 160. ecg is reported as sinus tachycardia with no st or t wave abnormalities. pt was started on vancomycin and ceftazidime for his pneumonia. sputum cultures from grew mrsa and pan resisitent pseudomonas. on , the pt lost iv access and attempts to replace it were unsuccesful. therefore, his antibiotics were changed to linezolid and ciprofloxacin(wanted to cover gram negatives). by , the patient had also developed complete collapse of the left lung. pulmonary service was consulted at that time but could not bronch the pt as he had no iv access. pt often became tachypnic at the outside hospital and required frequent suctioning. hypernatremia resolved with treatment with free water. on , the pt was sent to to have a picc placed. during picc placement in ir, the pt developed nausea and cp at approximately 3:30 pm. he was sent to the ed for futher evaluation. in the , pt's vs were initially 98.2, 70, 101/53, 18, and 98% on 70% face tent. pt received vancomycin 1 gm iv and 1 l of ns. ecg in the ed showed mildly at 470-480 and t wave inversion in v1-v4. pt was evaluated by cardiology and plan was made for medical management. he was placed on a heparin drip for pain control. the first set of cardiac enzymes were negative. past medical history: 1. traumatic brain injury s/p fall in 2. peg tube placement in 3. trach placed in for post-intubation subglottic tracheal stenosis per records. currently has t-tube. 4. history of dvt on coumadin with ivc filter 5. multiple aspiration pneumonia 6. s/p multiple abdominal surgeries for hernia repair 7. past seizure disorder 8. anemia 9. history of fungemia social history: married. polish immigrant (speaks some english). used to be a heavy smoker. has been a nursing home resident for many years since his tbi. has several children who are closely involved, one daughter is a ccu nurse at . family history: noncontributory physical exam: t: 96.6 bp: 127/50 p: 54 rr: 24, o2 sat 95% on 50% tc (pt does not desaturate with nasal cannula, but just prefers not to wear it) gen: awake, alert, sitting up in chair skin: warm and dry heent: + copious secretions from tracheostomy heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops lungs: coarse throughout, moving air much better on the left abd: soft, nontender, nondistended. ventral hernia nontender, easily reducible. +bs. ext: no edema, 2+ distal pulses bilaterally. pertinent results: 04:04am blood wbc-5.3 rbc-2.93* hgb-8.4* hct-25.7* mcv-88 mch-28.7 mchc-32.7 rdw-17.3* plt ct-382 04:00am blood wbc-7.3 rbc-2.92* hgb-8.4* hct-25.9* mcv-89 mch-28.9 mchc-32.6 rdw-16.4* plt ct-358 07:35am blood wbc-5.6 rbc-3.07*# hgb-8.7*# hct-26.9* mcv-88# mch-28.4 mchc-32.4 rdw-16.6* plt ct-381 04:51am blood wbc-4.7 rbc-2.31* hgb-6.6* hct-22.1* mcv-96# mch-28.6 mchc-29.9*# rdw-16.0* plt ct-312 03:50am blood wbc-7.6 rbc-2.97* hgb-8.8* hct-25.8* mcv-87 mch-29.8 mchc-34.3# rdw-16.8* plt ct-397 05:30pm blood hct-25.0* 06:03am blood wbc-8.3 rbc-3.10* hgb-8.6* hct-27.7* mcv-89 mch-27.8 mchc-31.1 rdw-16.2* plt ct-397 04:25pm blood wbc-7.0 rbc-2.97* hgb-8.5* hct-26.0* mcv-88 mch-28.5 mchc-32.5 rdw-15.9* plt ct-319 04:00am blood neuts-71.0* lymphs-23.2 monos-4.0 eos-1.6 baso-0.2 04:04am blood plt ct-382 04:04am blood pt-13.7* ptt-32.5 inr(pt)-1.2 04:00am blood pt-15.6* ptt-36.5* inr(pt)-1.5 07:35am blood pt-16.9* ptt-37.6* inr(pt)-1.8 04:51am blood pt-17.4* ptt-41.8* inr(pt)-1.9 03:50am blood pt-15.2* ptt-35.3* inr(pt)-1.5 06:03am blood pt-14.2* ptt-53.1* inr(pt)-1.3 10:14pm blood pt-14.7* ptt-119.1* inr(pt)-1.4 04:25pm blood pt-13.1 ptt-30.2 inr(pt)-1.1 04:00am blood glucose-109* urean-14 creat-1.1 na-146* k-3.6 cl-111* hco3-27 angap-12 07:35am blood glucose-86 urean-15 creat-1.0 na-149* k-3.5 cl-114* hco3-28 angap-11 04:51am blood glucose-732* urean-13 creat-0.9 na-137 k-3.0* cl-107 hco3-25 angap-8 08:30pm blood k-4.1 06:03am blood glucose-101 urean-28* creat-1.1 na-148* k-3.3 cl-110* hco3-28 angap-13 10:14pm blood glucose-437* urean-30* creat-1.1 na-145 k-3.4 cl-108 hco3-28 angap-12 04:25pm blood glucose-69* urean-32* creat-1.2 na-150* k-4.0 cl-111* hco3-30* angap-13 06:03am blood alt-73* ast-32 ck(cpk)-97 alkphos-66 totbili-0.2 10:14pm blood ck(cpk)-91 04:25pm blood alt-93* ast-40 ld(ldh)-211 ck(cpk)-113 alkphos-65 amylase-30 totbili-0.3 06:03am blood ck-mb-2 ctropnt-<0.01 10:14pm blood ck-mb-notdone ctropnt-<0.01 04:25pm blood ck-mb-1 ctropnt-<0.01 04:25pm blood lipase-14 04:04am blood calcium-7.4* phos-3.7 mg-2.0 04:00am blood calcium-7.3* phos-3.7 mg-1.8 07:35am blood calcium-7.3* phos-3.7 mg-2.0 04:51am blood calcium-6.0* phos-3.0 mg-1.7 03:50am blood calcium-7.2* phos-2.4* mg-2.1 06:03am blood calcium-7.9* phos-2.6* mg-1.9 10:14pm blood calcium-6.9* phos-2.9 mg-1.9 04:25pm blood albumin-2.3* calcium-8.0* phos-3.3 mg-2.1 04:04am blood valproa-38* 07:35am blood valproa-5* 03:50am blood valproa-4* 04:25pm blood valproa-20* 04:33pm blood hct-28.8* brief hospital course: 1. respiratory: mr. presented to the osh with a pneumonia which grew 3 different bacteria: mrsa and 2 strains of pseudomonas. one strain of pseudomonas was pan-resistant, and the other one was resistant to everything except ceftazidime and pipercillin. while here, the pt remained afebrile and his blood pressure was stable. his oxygen requirement remained the same. he had copious secretions and -out left lung on cxr, and so underwent bronchoscopy on . it revealed quite a bit of secretions in his upper airways, as well as a 95% dynamic collapse of his trachea distal to the t-tube. in this area there was also what appeared to extrinsic compression of his trachea, and the pulmonary attending recommended a ct scan to evaluate this in the future. after the bronch, he did well with aggressive chest pt, positioning, and guafenesin. he had a vibrating vest placed on his chest which helped break up secretions, but the pt did not tolerate this. he also had scheduled nebs while he was here, as he was wheezing on exam initially. his cxr looked better on discharge although he still has some degree of collapse on his left side. for his pneumonia, given his hx of mrsa and pseudomonas (one of which was sensitive to ceftaz), he was treated with vancomycin and ceftazidime, discharged to finish a 10-day course, 1st day = . he also had a chest ct done to evaluate the possibility of his trachea being extrinsically compressed, which showed: 1) narrowed intrathoracic trachea and narrowed right and left main bronchi consistent with tracheomalacia, 2) enlarged thyroid with slight heterogeneous attenuation of the right thyroid lobe, 3) bilateral moderate-sized pleural effusions, 4) right lower lobe atelectasis, 5) left upper lobe and left lower lobe opacities. there is likely a combination of atelectasis and pneumonia, 6) left posterior 9th and 10th rib fractures, likely acute, 7) emphysema. 2. cardiovascular: on , during placement of a picc line by interventional radiology the pt developed chest pain. he had an ekg done at that time which showed t wave inversions in v1-v4 but no st-t changes (none available for comparison). he was begun on a heparin gtt, and his pain resolved. he had negative cardiac enzymes x3 sets. he was begun on an asa and a statin. his heparin gtt was discontinued the next morning. we attempted to start a beta blocker on him, but his pulse was often in the 40s-50s (sinus bradycardia) and so he did not tolerate it. he was evaluated by cardiology who felt that he could have an echo or ett as an outpatient to evaluate ef and wall motion abnormalities. it was felt that his chest pain was likely his 5 broken ribs sustained in a fall 2 weeks ago at the nursing home. for this reason, his asa, statin, and beta-blocker were all discontinued as we have no evidence that he actually has any coronary artery disease. in terms of his hx of dvt, he takes coumadin 10 mg qd at the nursing home. coumadin was not one of his medications listed on transfer from -. in our ed, he was begun on a heparin gtt his chest pain. his coumadin was restarted on at his home dose. 3. gi: pt was begun on tube feeds, which were cycled at night per his nh protocol. he tolerated these well and they were quickly advanced to goal without complication. his abd pain that he had in ir had resolved by the time he was admitted to the . 4. hematology: pt was anemic on admission at 26. he carries a diagnosis of chronic anemia, and his crit was stable throughout his stay. he received one unit of prbcs the evening of admission (given the possibility of cad), but basically hovered in the 25-27 range throughout his stay. he had no signs of active bleeding, and it's recommended that this be followed up as an outpt. his hematocrit was 24.6 at its lowest point, and was 28 on discharge. 5. neuro: he has been on depakote for a hx of seizure disorder, and when he came in his level was 20 (goal 50-100). he was placed on his home dosing of depakote () but apparently it was only given in the am, and so his level dropped to 5. this was corrected, and his level should be followed up as an outpt. his level prior to discharge was 35. he had no seizure activity while he was here. 6. musculoskeletal: he has 5 left-sided posterior rib fractures sustained in a fall at the nursing home 2 weeks ago. for this, his pain was controlled with subcutaneous dilaudid. medications on admission: linezolid 600 mg ciprofloxacin 500 mg zoloft 100 mg po qd albuterol nebs q4h prn dilaudid prn prilosec 20 mg qd valproic acid (250 mg in 5 ml syrup) 15 cc qam, 20 cc qpm discharge medications: 1. valproate sodium (bulk) 250 mg/5 ml syrup sig: twenty (20) cc po qpm (once a day (in the evening)). 2. valproate sodium (bulk) 250 mg/5 ml syrup sig: twenty (20) cc po qam (once a day (in the morning)). 3. acetaminophen 650 mg suppository sig: one (1) suppository rectal q4-6h (every 4 to 6 hours) as needed for fever, pain. 4. sertraline hcl 50 mg tablet sig: two (2) tablet po qd (once a day). 5. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. neb 6. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheezing, sob. 7. hydromorphone hcl 2 mg/ml syringe sig: 0.5-1 mg injection q6h (every 6 hours) as needed. 8. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed. 9. warfarin sodium 5 mg tablet sig: two (2) tablet po qd (once a day). 10. vancomycin hcl 1,000 mg recon soln sig: one (1) gram intravenous every twelve (12) hours for 4 days: last dose 9/26 for a total 10 days treatment. 11. ceftazidime 1 g recon soln sig: one (1) gram intravenous every eight (8) hours for 4 days: last dose on , for a total 10 days treatment. discharge disposition: extended care facility: hospital - discharge diagnosis: pneumonia with left lung collapse discharge condition: stable discharge instructions: please take your medications as directed. please use aggressive chest physical therapy (pt tolerates, despite broken ribs), suctioning, and expectorants (i.e. guaifenesin or humibid). followup instructions: please be evaluated by your pcp upon arrival at the nh. please have your valproic acid level checked 2-3x/wk. please have your inr checked at the same time, as we have restarted your coumadin. procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances bronchoscopy through artificial stoma transfusion of packed cells diagnoses: other convulsions pulmonary collapse pneumonia due to pseudomonas other emphysema methicillin susceptible pneumonia due to staphylococcus aureus fall from other slipping, tripping, or stumbling tracheostomy status closed fracture of five ribs 

Answer: The patient is high likely exposed to