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: aspirin / iodine / carafate / tagamet / mylanta attending: chief complaint: shortness of breath major surgical or invasive procedure: left internal jugular vein catheterization picc line placement history of present illness: mrs. is an 85 year old female with a history of cad, atrial fibrillation and congestive heart failure who was transferred from hospital with fevers, cough and vomiting. the patient has recently been in and out of the hospital four times over the past six weeks for urinary tract infections and aspiration events now s/p peg placement two weeks ago. she currently presents from rehab with feves, cough and congestion x 2 days and vomiting x 1 day. she was also noted to have tachypnea and dizziness at her rehab. per the micu admission note on presentation to hospital she was noted to be afebrile, tachycardic to the low 100s with stable blood pressrue. she later spiked a fever to 102.4 and developed an oxygen requirement. her labs were notable for a sodium of 125, wbc count of 17.3 with 34% bands. cxr at showed no focal infiltrates but was suggestive of mild chf. she was treated with ceftriaxone and azithromycin for possible pneumonia. she received 500 cc ivf with increased tachypnea and was subsequently given nitropaste for possible chf exacerbation. she was transferred to for further management. in the emergency room her initial vital signs were t; 99.3 hf: 130 (atril fibrillation), bp: 90/50 o2: 98% on ra. initial labs were notable for leukocytosis and bandemia (wbc count of 23.1 with 9% bands), bnp of 4181, initial lactate of 3.1 which improved to 2.1 with gentle hydration. she had a negative ua. her cxr showed some questionable interstitial edema with no focal infiltrates. she had blood cultures sent. she received vancomycin in additio to the previously received ceftriaxone and azithromycin. she alos received 2l of normal saline with improvement in her blood pressure. she was transferred to the icu for further management. while in the icu her hemodynamics improved. her antibiotics were changed to vancomycin, cefepime and azithromycin. she had left ij central line placed for iv access. she had a negative dfa. she had a sputum culture which was polymicrobial and cultures are pending. urine culture was negative. blood cultures were drawn and were negative to date. she was transiently hypotensive the afternoon of micu transfer in the setting of receiving her home dose of diltaizem. her blood pressure quickly improved with 250 ns bolus. she is transferred to the floor for further management. on review of systems she denies fevers, chills, lightheadedness, dizziness, chest pain, dyspnea, nausea, vomtiing, abdominal pain, diarrhea, constipation, dysuria, hematuria, leg pain or swelling. she does report fatigue. all other review of systems negative in detail. past medical history: -cad (per pt no h/o mi) -chf (per pt's son, due to "irregular hr") -htn -atrial fibrillation on coumadin -catarcts -asthma -g tube placed 2 weeks ago for recurrent aspiration event -recent recurrent uti -dementia social history: lives at home w/ son and daughter-in-law, but as per hpi, recent numerous hospitalizations so presents from rehab (per report, came from ? country manor nursing home). never smoked. family history: n/c physical exam: vitals - t 96.1, hr 104, bp 91/47, rr 20, o2 98% on 3l nc gen - awake, alert, conversive, oriented to person, , hospital heent - perrl, eomi, oropharynx clear, mmm neck - jvp approx 8-10 cm, no bruits heart: soft heart sounds, irregularly irregular, no appreciable murmurs, rubs, gallops lungs - scattered crackles throughout, no wheezes or ronchi abd - soft, nt/nd, g tube in place, site without erythema or purulence ext - wwp, 2+ pulses, trace edema bilaterally pertinent results: hematology: 05:28pm wbc-23.1* rbc-3.42* hgb-10.5* hct-32.1* mcv-94 mch-30.8 mchc-32.8 rdw-16.4* 05:28pm neuts-78* bands-9* lymphs-4* monos-6 eos-0 basos-0 atyps-0 metas-2* myelos-1* 05:28pm hypochrom-normal anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-occasional polychrom-1+ ovalocyt-occasional 05:28pm plt smr-very high plt count-873* 06:05am wbc-20.4* rbc-3.34*# hgb-10.1*# hct-30.5*# mcv-91 mch-30.1 mchc-33.0 rdw-16.3* plt-388 05:54am neuts-71* bands-1 lymphs-9* monos-3 eos-12* basos-0 atyps-0 2* metas-2* myelos-1* chemistries: 05:28pm blood glucose-123* urean-32* creat-1.0 na-132* k-5.3* cl-96 hco3-21* angap-20 05:28pm blood calcium-9.3 phos-4.5 mg-1.8 05:00am blood calcium-8.0* phos-1.5* mg-1.5* 05:54am blood calcium-8.5 phos-3.0 mg-1.7 cardiac enzymes: 05:28pm blood ck-mb-notdone probnp-4181* 05:28pm blood ctropnt-0.02* 05:28pm blood ck(cpk)-26 11:00pm blood ck-mb-notdone 11:00pm blood ck(cpk)-24* 07:09am blood ck-mb-notdone ctropnt-0.02* 07:09am blood ck(cpk)-23* other laboratories: 05:43am blood caltibc-177* vitb12-1337* folate-19.3 ferritn-442* trf-136* 05:00am blood osmolal-271* 05:40pm blood glucose-113* lactate-3.1* na-131* k-4.9 cl-98* 08:03pm blood lactate-2.0 12:06am blood lactate-1.3 07:16am blood lactate-0.9 06:05am blood vacomycin-26.6 urinalysis: 05:28pm urine color-yellow appear-clear sp -1.014 blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-9.0* leuk-tr rbc-0-2 wbc- bacteria-mod yeast-none epi-0 3phosphat-mod 01:05pm urine color-straw appear-clear sp -1.011 blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-tr rbc-0-2 wbc-* bacteri-occ yeast-few epi-0 01:05pm urine hours-random creat-25 na-108 01:05pm urine osmolal-404 ekg : sinus tachycardia. borderline low limb lead voltage. no previous tracing available for comparison. imaging: cxr : some pulmonary vascular congestion and blurring with nterstitial edema. no overt edema or pleural effusion. no focal consolidation. microbiology: blood cultures from x 2 - negative final blood cultures from x 2 - no growth to date at time of discharge urine cultures from - negative urine culture from - yeast dfa for inflenza a/b - negative stool for clostridium difficile , , and - negative 3:04 am sputum source: expectorated. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). 3+ (5-10 per 1000x field): gram positive cocci. in clusters. 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): yeast(s). 1+ (<1 per 1000x field): gram negative diplococci. respiratory culture (final ): moderate growth oropharyngeal flora. proteus mirabilis. moderate growth. presumptive identification. staph aureus coag +. moderate growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | staph aureus coag + | | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- 8 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s ciprofloxacin--------- =>4 r clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ 4 s <=0.5 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- 8 s piperacillin/tazo----- <=4 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ 2 s trimethoprim/sulfa---- =>16 r <=0.5 s vancomycin------------ <=1 s brief hospital course: mrs. is an 85 year old female with a history of cad, atrial fibrillation and recent recurrent hospitalizations for urinary tract infections and aspiration pneumonia who presents with fever, tachypnea, hypoxia and hypotension. fevers/leukocytosis, likely due to septicemia, nos, and bacterial/aspiration pneumonia: the patient presented with fevers to 102 degrees with a leukocytosis and bandemia. she also had an elevated lactate on presentation to 3.1 with mild hypotension in the setting of rapid atrial fibrillation. her only localizing symptoms were tachypnea and mild oxygen requirement. a broad infectious workup was performed including blood cultures, urine cultures, sputum cultures and c. difficile toxin. on admission her ua was trace positive with a urine ph of 9.0. blood and urine cultures, however, were negative. she had a negative dfa. she had four negative c. diff toxin assays. she had a cxr which showed no focal consolidations. she had a sputum culture which grew proteus and mrsa. on admission to this hospital her antibiotic coverage was switched to vancomycin, cefepime and azithromycin to cover hospital acquired pneumonia as well as urinary pathogens. this was subsequently changed to vancomycin and ceftriaxone given sensitivities of organisms. her mild hypotension and elevated lactate quickly improved with fluid boluses. her fevers quickly resolved. her leukocytosis however, persisted. on admission her wbc count was 23.1 with 78% neutrophils and 9% bands. after initiation of broad spectrum antibiotics her wbc count decreased only slightly despite improvement in her symptoms and resolution of her fevers. initially her differential was left shifted but prior to discharge this had transitioned to a 12% eosinophilia with rare myelocytes and metamyelocytes. it was thought that her persistent leukocytosis was secondary to her antibiotics. she has plans to complete a 14 day course of antibiotics with vancomycin and ceftriaxone for her proteus and mrsa in the sputum. her vancomycin is being dosed by level. on discharge her level was 26.6. her vancomycin trough should be checked daily and she should be given 1 gram of vancomycin when her trough falls to below 20. her cbc and differential should be rechecked one week after completion of therapy to ensure improvement in her leukocytosis. if she continues to have immature cells in her peripheral blood differential or a persistent leukocytosis, hematology consultation should be considered as an outpatient. anemia: on admission the patient's hematocrit was 32.1 but this decreased rapidly to 26.2 after gentle fluid hydration. for the remainder of her hospitalization her hematocrit was stable between 23 and 26. during this hosptilization her folate and b12 were checked and were normal. her iron was measured at 33 with a ferritin 442 consistent with anemia of inflammation. prior to discharge she was transfused one unit of prbcs. her hematocrit should also be checked in one week to ensure stability. hyponatremia: on presentation to the osh the patient's serum sodium was 125. with gentle fluid hydration this improved to 132 on arrival to this hospital. studies performed on presentation here revealed a serum osmolality of 271 with a urine osmolality 404 which was inappropriately elevated consistent with siadh, likely due to pulmonary process. she was continued on her standard tube feeds. her sodium remained between 130 and 134. no further interventions were made. congestive heart failure: per report the patient has a history of congestive heart failure. there are no echocardiograms in our system and it is unclear whether her heart failure is systolic vs. diastolic. on presentation her initial cxr showed mild pulmonary edema and her bnp was elevated in the 4000s. her oxygenation saturation on arrival here was 98% on ra. initially her home chf regimen was held out of concern for hypotension and possible sepsis. her blood pressures remained in the 100s systolic during her hospitalization and on discharge she was tolerating metoprolol 12.5 mg but her home aldactone was not able to be restarted. her aldactone should be restarted as an outpatient once her acute illness has resolved. coronary artery disease: again, this is per patient history. her ekg on presentation had no changes concerning for ischemia. she had three sets of negative cardiac enzymes. she was continued on her home doses of lipitor and plavix. she was also started on metoprolol 12.5 mg bbid. atrial fibrillation: on arrival to this hospital the patient was in atrial fibrillation with rapid ventricular response. this was in the setting of acute infection. previously she was taking diltiazem for rate control. given her history of heart failure and coronary artery disease she was transitioned to metoprolol 12.5 mg for rate control. she tolerated this medication well. for the majority of her hospitalization she was in sinus rhythm. she was continued on coumadin for anticoagulation. nutrition: the patient had a peg tube placed two weeks ago for tube feeds given frequent aspiration events over the past six months. on hospital day three the patient was noted to have decreased potassium, magnesium and phosphorous concerning for refeeding syndrome. the rate of her tube feeds was decreased and her electrolytes were repleted aggressively. her electrolyte abnormalities quickly resolved. she was placed back on her full rate of tube feeds which she subsequently tolerated well. prophylaxis: she was continued on coumadin for her atrial fibrillation was well as dvt prophylaxis. access: she currently has a single lumen picc in place for iv antibiotics. fen: tube feeds at 55 cc/hr, npo, aspiration precautions code status: dnr/dni confirmed with patient and patient's son who is her health care proxy. communication: son who is pt's hcp, , ( medications on admission: cardizem 120 mg tid plavix 75 mg daily aldactone 50 mg daily prevacid 15 mg daily calcium carbonate 1,000 mg tid albuterol 90 mcg inh qid lexapro 10 mg daily lipitor 20 mg daily coumadin 4 mg 2 times/week coumadin 2 mg 5 times/week discharge medications: 1. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 2. calcium carbonate 500 mg tablet, chewable : two (2) tablet, chewable po tid (3 times a day). 3. albuterol 90 mcg/actuation aerosol : two (2) puff inhalation q4h (every 4 hours) as needed. 4. escitalopram 10 mg tablet : one (1) tablet po daily (daily). 5. atorvastatin 10 mg tablet : two (2) tablet po daily (daily). 6. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 7. warfarin 2 mg tablet : one (1) tablet po daily16 (once daily at 16). 8. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 9. ceftriaxone-dextrose (iso-osm) 1 gram/50 ml piggyback : one (1) intravenous q24h (every 24 hours). 10. prevacid 15 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr once a day. 11. vancomycin 1,000 mg recon soln : one (1) intravenous dosed by level for 6 days: vancomycin level should be checked . dose should be given if trough < 20. subsequently should be dosed by level for trough 15-20. . discharge disposition: extended care facility: - discharge diagnosis: primary: pneumonia secondary: hypertension coronary artery disease chronic congestive heart failure (ejection fraction unknown) asthma dementia atrial fibrillation discharge condition: stable. breathing comfortably on room air. requiring significant assistance for ambulation. discharge instructions: you were seen and evaluated for your fevers and cough. you were thought to have a pneumonia. you were treated with antibiotics. you were found to have a high white blood cell count. although your symptoms improved your white blood cell count did not. this should be rechecked after you complete your antibiotics for your pneumonia. please take all your medications as prescribed. the following changes have been made to your medication regimen. 1. please take ceftriaxone 1 gram iv every 24 hours for 6 more days 2. please take vancomycin 1 gram for six more days. dose will need to be adjusted by level for target trough of 15-20. vancomycin level should be checked on and dosed as appropriate. 3. please take coumadin 2 mg daily instead of alternating with 4 mg. inr should be rechecked on and coumadin dosing should be adjusted for a target inr between . 4. please stop taking cardizem 5. please stop taking aldactone. this medication should be restarted as an outpatient once the patient has improved clinically. 6. please take metoprolol 12.5 mg two times per ngt a day please keep all your follow up appointments. please seek immediate medical attention if you experience any fevers > 101 degrees, chest pain, trouble breathing, worsening cough, significant diarrhea, or any other concerning symptoms. followup instructions: please follow up with your primary care physician within one week of discharge from rehab. his office phone number is . patient should have repeat cbc with differential one week after completion of antibiotic therapy to assure resolution of her leukocytosis and eosinophilia. procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances transfusion of packed cells diagnoses: coronary atherosclerosis of native coronary artery pneumonia due to other gram-negative bacteria congestive heart failure, unspecified unspecified essential hypertension unspecified septicemia atrial fibrillation infection with microorganisms resistant to penicillins asthma, unspecified type, unspecified other persistent mental disorders due to conditions classified elsewhere pneumonitis due to inhalation of food or vomitus long-term (current) use of anticoagulants methicillin susceptible pneumonia due to staphylococcus aureus acute on chronic systolic heart failure other disorders of neurohypophysis gastrostomy status 

Answer: The patient is high likely exposed to