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 / lipitor attending: chief complaint: hypoxia major surgical or invasive procedure: intubation, extubation. mechanical ventilation. arterial line placement (in ed) central venous line placement (in ed) bronchoscopy picc line placement tracheostomy and g-tube placement () history of present illness: 78 y/o f bronchiectasis, severe copd with baseline 2l 02 requirement, tracheobronchomalacia s/p y-stent who presents with acute respiratory distress. patient initially presented to hospital speaking in 1 word sentances, tripoding, found to have an abg 7.22/110/176/43 and was consequently intubated. patient was given solmedrol 125 mg iv, levofloxacin and zosyn. per records patient had a cxr which demonstrated right pleural effusion and rll infiltrate. . in ed, initial vs were: t 98 p 120 bp 137/70. patient was felt to be desynchronous on vent, started on propofol became hypotensive and was switched over to versed. central line was placed and 3 l ns given. patient was also given vancomycin. labs pertinent for a lactate of 4, left shift n 91.5%, platelets 122. . according to family patient demonstrated increasing respiratory distress the past week and yesterday "lungs sounded junky". she was also increasingly somnelent and confused the past week. they denie fever, chills, abdominal pain, nausea, vomiting, headaches, vision changes, neck stiffness or chest pain. the do report decreased fluid intake. . of note, patient was recently admitted for h1n1 influenza, copd exacerbation with pseudomonas growing from sputum, urinary tract infection (+ esbl). patient discharged on ertapenem for 10 days total. . review of systems: patient intubated. past medical history: copd/tracheobronchomalacia s/p y stent placement . 3 other admissions and 9 therapeutic bronchoscopies since y stent placement. patient had bronchoscopy which ensured patent stent, minimal secretions, small amount of granulation tissue at the distal limb of the stent. pfts fev/fvc 44% . bronchiectasis htn gerd hypothyroid hyperlipidemia anxiety recurrent uti anemia hysterectomy at 33yo from anemia b/l cataract sx total knee replacement 2yrs ago bladder sling social history: has 4 children, all live locally; daughter is nurse. worked as a store clerk, retired 3 years ago. volunteered at until 4-5 months ago. drinks wine infrequently. no h/o tobacco or illicit drug use. husband smoked until ~22 yrs ago. daughter is a nurse. reports decreased appetite and enthusiasm for eating in past year, markedly decreased activity and exercise tolerance, weight loss. family history: mother had mi, brother died from heart disease and had minor stroke. no family history of lung disease/copd/asthma. 4 children and 7 grandchildren are generally healthy; grandaughter has spherocytosis and was recently hospitalized for 5 days with flu physical exam: general: thin, elderly female, intubation heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. drymm. op clear. cardiac: distant heart sounds. regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: limited air movement bilaterally, no wheezes or crackles abdomen: nabs. soft, nt, mildly firm. no hsm. extremities: no clubbing/ cyanosis/ edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. cool extremity. skin: no rashes/lesions, ecchymoses. neuro: will squeeze hands to name. pertinent results: chem 10 139 99 21 195 agap=13 3.8 31 0.6 ca: 8.1 mg: 1.1 p: 2.7 . ck: 24 mb: notdone trop-t: <0.01 . alt: 22 ap: 45 tbili: 0.2 alb: ast: 34 ldh: 187 . cbc 91 7.9 > 10.0 < 122 &#8710; 31.2 n:91.5 l:6.8 m:1.5 e:0 bas:0.2 . pt: 13.2 ptt: 27.7 inr: 1.1 . micro: blood culture ngtd urine culture ngtd . prior micro: sputum: pseudomonas aeruginosa cefepime-------------- 16 i ceftazidime----------- 32 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- =>128 r tobramycin------------ <=1 s . urine culture : escherichia coli ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r . images: cxr: my read - hyperinflated. increased hilar vasculature. no infiltrate. . ekg: : ekg hr 99, st depressions ii, iii, avf. on admission: hr 103, st depressions resolved. difficult baseline. . cta (prelim): 1. no pulmonary embolus or aortic dissection is seen. 2. emphysematous changes with diffuse bronchiectasis. there are new scattered opacities in the bibasilar regions which most likely represent atelectasis, less likely pneumonia. clinical correlation recommended. 3. stable et tube and tracheal y stent. 4. scattered 5 mm pulmonary nodules, some new. in a high-risk patient continued followup is recommended to assess stability. . lenis: right lower extremity ultrasound: -scale and doppler son of the right common femoral, femoral, popliteal, and calf veins was performed. there is normal flow, compressibility and augmentation of the veins. impression: no evidence of dvt in the right lower extremity. . cxr: findings: frontal chest radiograph is compared to the prior study from . endotracheal tube terminates in the thoracic inlet. lungs are clear. mediastinum is within normal limits. brief hospital course: 78 y/o f bronchiectasis, severe copd, tracheobronchomalacia s/p y-stent who presents with respiratory distress and hypotension. s/p trach and peg tube this admission, now being discharged to pulm rehab. see below for specific discussion of each problem. # respiratory distress: thought to be likely due to copd exaerbation with underlying component of tracheobronchomalacia and bronchiectasis. initial work-up revealed troponins negative for myocardial ischemia, pe cta negative for pulmonary embolus, and bronchoscopy/bronchoalveolar lavage with y-stent for tracheobronchomalacia in appropriate place. she was started on iv methylprednisolone 125mg iv q6h for presumed copd exacerbation, and this was gradually tapered. remained on q4h ipratropium and albuterol inhalers. respiratory cultures from grew gram negative rods. given previous respiratory cultures positive for pseudamonas, she completed a 12-day course of vancomycin and levofloxacin and an 11-day course of levofloxacin. for respiratory support, she was intubated on on ac ventilation. failed multipled trials of psv until finally on was successfully transitioned from ac to psv. was extubated on for 10 hours, then re-intubated due to respiratory distress and hypertension to 200s requiring a nitro drip. subsequently failed several spontaneous breathing trials (became hypertensive and tachycardic during these periods) with significant distress. discussed treatment options with healthcare proxy (daughter) and rest of family, who ultimately decided on tracheostomy and g-tube placement. proceeded with trache/g-tube placement on and worked with respiratory therapist to wean off mechanical ventilation. on the trach mask, she has been weaned slowly but still continues to be pretty symptomatic when ps is <10. has been stable on for approximately a day. mostly seen is tachycardia when she becomes uncomfortable. # hypotension: patient arrived to micu with elevated lactate concerning for shock, however there was no evidence of end organ damage (adequate urine output, normal creatinine). concern for sepsis based on left shift and prior esbl urinary tract infection and pseudomonas pneumonia. however, ua was negative, cxr showed no infiltrate, negative blood cultures to date and patient remained afebrile. cvp 8 following 3 l ns suggesting hypovolemia from poor po intake and unlikely cardiac shock. treated with broad spectrum antibiotics for possible infection as above. has been stable with sbps in 120s when awake. intermittently drops to the 80s when sleeping, usually in conjunction with getting ativan. # respiratory acidosis: initial abg showed respitory acidosis without adequate compensation most likely secondary to overlying metabolic acidosis from elevated lactate. patient's abg resolved quickly during micu stay, on mechanical ventilation. lactate normalized with fluid hydration. # acute on chronic anemia: slightly down on arrival at 27.7, from baseline 34-37. guaiac negative on exam. transfused 1u prbcs on and to a hct 31.7. hematocrit remained stable for duration of hospital stay. # tachycardia: patient was initially tachycardic with temporary improvement with blood transfusion. patient remained intermittently tachycardic, usually during times of respiratory distress or anxiety. hr improved with sedation, optimization of ventilator settings and initiating of beta-blocker. she is on metoprolol 25 mg ; we tried to go to tid and she did not tolerated with moderately low bps in the 90s. # anxiety: patient has baseline anxiety. she was continued on home mitrazapine 15 mg hs. additional anxiolytic effects achieved with iv sedation (propofol) while on ventilator as well as ativan (0.25-0.5mg q6h, which is close to patient's home dose). she is on standing ativan and prn ativan per her home regimen. she still has intermittent anxiety. she seems to repsond well to sublingual zyprexa, too. # tracheobronchomalacia s/p y stent placement: continued outpatient stent care. patient underwent bronchoscopy by interventional pulmonary which confirmed good y-stent placement and patent airways. patient was continued on home regimen of guaifenesin 600 mg tablet and acetylcysteine 20 % (200 mg/ml) every 8 hours. # new thrombocytopenia: platels on admission 122 from baseline 300. platelets were trended daily and climbed to a normal baseline range during hospital stay. # impaired glucose control: blood sugar noted to be high in 200s in the hospital, felt to be secondary to steroids. placed on insuline sliding scale which was adjusted with the prednisone taper. will continue at rehab. # htn: was continued on lopressor 25mg , held when bp was low. held home dose of amlodipine. she has variable blood pressures based on her activity and anxiety levels. no flash edema noticed when she was high. # pain control: patient's pain was controlled with fentanyl 12.5-25 mcg iv q4h prn. she is still on fentanyl prn with good control. # gerd: remained on famotidine while intubated. # hypothyroid: continued outpatient levothyroxine. had tsh of 0.91 around admission. continued her home dose but should be rechecked when more stabalized. # hyperlipidemia: continued outpatient simvastatin. # fen: tube feeds via peg at 40ml/hr. at goal, tolerating well. zofran prn. # constipation: intermittent constipattion controlled on bowel regimen of colace 100 and senna prn. . # discharged to rehab. foley removed this afternoon. family aware and at bedside at the time of discharge. medications on admission: - ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). - guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid. - fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). - levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). - atenolol 50 mg tablet sig: one (1) tablet po daily (daily). - acetylcysteine 20 % (200 mg/ml) solution sig: one (1) ml miscellaneous q 8h (every 8 hours). - mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). - simvastatin 10 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). - albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation prn (as needed) as needed for see below: please use when giving mucinex. - levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for wheezing, dyspnea. - prednisone 5 mg tablet sig: one (1) tablet po qd () for 3 days. - omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). - methenamine hippurate 1 gram tablet sig: one (1) tablet po twice a day. - sucralfate 1 gram tablet sig: one (1) tablet po qchs. - asa 81 mg - norvasc 10 mg qd - ativan 0.25 mg po q6 hours anxiety - bipap at night with setting discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q4h (every 4 hours). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 6-8 puffs inhalation q2h (every 2 hours) as needed for respiratory distress. 4. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q4h (every 4 hours). 9. docusate sodium 50 mg/5 ml liquid sig: 50-100 mg po bid (2 times a day) as needed for constipation. 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. guaifenesin 100 mg/5 ml syrup sig: fifteen (15) ml po q6h (every 6 hours): in place of mucinex. 12. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours). 13. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 14. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po tid (3 times a day) as needed for aggitation: given sometimes before trach mask trials. 15. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 16. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 18. heparin, porcine (pf) 10 unit/ml syringe sig: ten (10) ml intravenous prn (as needed) as needed for line flush. 19. prednisone 10 mg tablet sig: three (3) tablet po daily (daily): 30mg for 3 days () then 20mg for 3 days () and then 10mg for 4 days () and then stop. 20. insulin lispro 100 unit/ml solution sig: one (1) unit subcutaneous asdir (as directed): please give as directed in the attached insulin sliding scale. discharge disposition: extended care facility: hospital transitional care unit - discharge diagnosis: primary: copd, tracheobronchomalacia s/p y-stent placement, bronchiectasis secondary: htn, hl, hypothyroidism, gerd, anxiety, depression discharge condition: discharged on trach mask with psv of . tolerating well with intermittent symptomatic anxiety. hr in 100s-110s. is awake and alert and can mouth words, likley intermittently hallucinating, too, but difficult to tell based on understanding when she mouths words discharge instructions: dear ms. , you were admitted to the medical center due to difficulty breathing. to help support your breathing you were placed on mechanical ventilation with a breathing tube. you were also given steroids to support your lung function and antibiotics (meropenem, vancomycin, and levofloxacin) for treatment of a presumed lung infection. to evaluate what was causing you to have such difficulty breathing, we conducted a number of tests, including a ct scan of your chest to look for blood clots, blood tests to determine if you had an injury to your heart, and a bronchoscopy to look at the stent in your airways. all of these tests came back negative for any injury. we believe that your respiratory distress is due to poor lung function from your underlying lung disease. we tried to wean you off of mechanical ventilation several times, including at one point taking the breathing tube out completely, but you became significantly distressed with all of these attempts. after ongoing discussion with your family, it was decided to insert a tracheostomy tube to help support your breathing. we also placed a g-tube to allow you to receive nutrition. you tolerated this procedure well. you will continue to work with a respiratory therapist in managing your breathing with the tracheostomy tube. followup instructions: - please follow up with your primary care physician as needed per doctors at the pulmonary rehab facility procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube fiber-optic bronchoscopy percutaneous [endoscopic] gastrostomy [peg] arterial catheterization temporary tracheostomy closed [endoscopic] biopsy of bronchus diagnoses: thrombocytopenia, unspecified anemia of other chronic disease anemia, unspecified unspecified pleural effusion obstructive chronic bronchitis with (acute) exacerbation dysthymic disorder acute and chronic respiratory failure malignant essential hypertension hypovolemia knee joint replacement tachycardia, unspecified other diseases of trachea and bronchus mixed acid-base balance disorder dependence on respirator, status bronchiectasis with acute exacerbation 

Answer: The patient is high likely exposed to