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: cephalosporins / morphine / fentanyl attending: chief complaint: somnolence, hypoxic resp failure major surgical or invasive procedure: r femoral line, now d/c'd right midline by ir history of present illness: 46 y/o m w/ h/o morbid obesity, copd, chronic trach dependence, dmii, pvd, s/p l bka, h/o klebsiella/proteus uti, pna, mrsa, vre, who presents with increasing somnolence and hypoxic respiratory failure . presented to er in respiratory distress, hypoxic to 40's at home. t to 101.trach noted to have copius secretions, which were aggressively suctioned, given o2, nebs, antibiotics (zosyn/vanco). improved respiratory status, but still somnolent and also noted to be hyperkalemic at 6.4. no ekg changes. given insulin/d50, calcium iv. kayexalate ordered (but not given pta). also had positive troponin of 0.05 (nl <0.01). acidotic at 7.16 w/ co2 of 65. therefore placed on vent for transport to . u/a at osh pos for wbc >100, bacteria, neg nitr, lge leuk's. hct 31.7, wbc 15.6, plt 358, 84.5%n. creat 2.6. . also as patient was leaving, patient care technician who cares for patient at home says he may have fallen the night pta. . in ed here. vitals on arrival t99.8, bp 119/51, rr 16, 99% on vent. vanco infusing. bp's subsequently dropped to 80's syst-> then 69/34. recieved 2l ns ivf pta and given 1 more l ns in ed. started on dopa gtt at 5mcg/kg/min, titrated up to 10 mcg/kg/min. bp initially up to 100's systolic, then back down to 80's. changed to levophed gtt. asa 325mg given. trach tube changed to portex 6.0, cuffed to vent 600/100/16/5. bp subsequently up to 150's systolic. . vanco given at 1700. zosyn 4.5 gm prior to arrival at 1415. also given 10 u insulin, 1 amp d50, 1 gm ca gluconate. r femoral line placed under u/s guidance. ekg w/ nsr. nl axis. twi v1, 1mm st elev 2. . recent admission for presumed urosepsis. . past medical history: 1) dm2 diagnosed with triopathy: creatinine has been as low as 0.8 in the last couple of years, however widely fluctuant, as high as 2 in the recent past. 0.9 in . 2) copd, on home o2. multiple episodes of respiratory failure requiring intubation in recent years. most recently, was admitted in with a perforated transverse colon requiring partial colectomy and transverse colostomy. this course c/b anticipated respiratory failure and anticipatory tracheostomy, pseudomonal and mrsa pna. also with acalculous cholecystitis requiring cholecystostomy tube. had g-tube placed. 3) osa on cpap 3) vre 4) s/p tracheostomy, as above in 5) htn 6) chf: during hospitalization in it was thought that failure contributed to his respiratory failure. last echo was in at which time lvef thought to be roughly normal, however very poor study and rv not visualized. not on lasix. 7) anemia of chronic disease, multiple transfusions in the past 8) s/p bka for chronic le ulcer 9) tia in . 10) difficult intubation; fiberoptic guidance in of . 11) urinary retention. 12) osteoarthritis. 13) depression. 14) c. difficile in . 15) hypogonadism. 16) morbid obesity . past surgical history: 1. bilateral carpal tunnel release in . 2. hydrocele repair in . 3. quadriceps tendon repair in . 4. status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube and percutaneous tracheostomy on . social history: lives home alone with vna. denies etoh. remote cigar smoking, no cigarettes. no ivdu or marijuana. has 1 brother, . family history: non-contributory physical exam: physical exam- t 99.8, bp 107/38, hr 75, rr 24, 100% ac 24 x 600. 100fio2. 10 peep gen- sleepy but arousable to voice heent- pupils equal and reactive 3->2 b/l. op clear neck- trach in place, no purulent secretions pulm- ant w/ coars b/s b/l. no focal ronchi or rales cv- distant heart sounds, rrr. no m/r/g abd- b/l osteomies intact w/o erythema. midline erythematous scar tissue w/o ulceration. ext- 2+ pedal edema on r. r dist le cellulitis w/o ulceration. l bka w/o cellulitic change. stump clean back- no sacral decub. small area of erythema on r upper buttocks dressed w/ guaze neuro-able to grip hands b/l= equal strength. wiggles r toes. sticks out tongue. opens eyes to voice. pertinent results: radiology: ======== cxr : tracheostomy tube, nasogastric tube, and right picc line remain in place, with a right picc line continues to terminate in the right subclavian vein. cardiac silhouette remains enlarged, and there is persistent increased pulmonary vascularity as well as perihilar haziness and bilateral moderate pleural effusions. overall, there has not been a significant change in degree of chf. . leni rle - impression: technically difficult exam, but no evidence for dvt . tte : suboptimal technical quality. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size is normal. the aortic valve leaflets appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. picc - impression: 1. the tip of the right-sided picc line in the distal portion of the right subclavian vein. 2. moderate congestive heart failure with cardiomegaly and small bilateral pleural effusion. bibasilar patchy atelectasis . leni b/l le's- impression: no evidence for dvt. . micro data: ========== 7:04 am sputum source: expectorated. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): sparse growth oropharyngeal flora. citrobacter koseri. sparse growth. work-up request per dr . this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. pseudomonas aeruginosa. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter koseri | pseudomonas aeruginosa | | cefepime-------------- <=1 s 8 s ceftazidime----------- 4 s 32 r ceftriaxone----------- 16 i ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s 2 s imipenem-------------- <=1 s =>16 r levofloxacin---------- =>8 r meropenem-------------<=0.25 s 8 i piperacillin---------- =>128 r 64 s piperacillin/tazo----- 64 i 64 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r . 1:52 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). respiratory culture (final ): sparse growth oropharyngeal flora. staph aureus coag +. moderate growth. of two colonial morphologies. pseudomonas aeruginosa. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | pseudomonas aeruginosa | | cefepime-------------- 16 i ceftazidime----------- =>64 r ciprofloxacin--------- =>4 r clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s 2 s imipenem-------------- 8 i levofloxacin---------- =>8 r meropenem------------- 8 i oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- =>128 r piperacillin/tazo----- 64 s rifampin-------------- <=0.5 s tetracycline---------- 2 s tobramycin------------ <=1 s vancomycin------------ <=1 s . 1:52 am urine **final report ** urine culture (final ): klebsiella pneumoniae. >100,000 organisms/ml.. 2nd isolate. <10,000 organisms/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s nitrofurantoin-------- 256 r piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . . sputum : gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 4+ (>10 per 1000x field): gram negative diplococci. 2+ (1-5 per 1000x field): gram positive cocci in pairs. smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. acinetobacter baumannii. heavy growth. pseudomonas aeruginosa. heavy growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ acinetobacter baumannii | pseudomonas aeruginosa | | cefepime-------------- 16 i 16 i ceftazidime----------- =>64 r =>64 r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ 2 s 2 s imipenem-------------- 8 i 8 i levofloxacin---------- 4 i meropenem------------- 8 i piperacillin---------- =>128 r piperacillin/tazo----- 64 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: 46 y/o m w/ h/o morbid obesity, chronic trach dependence secondary to osa, dmii, pvd, s/p l bka, h/o klebsiella/proteus uti, mrsa/vre pneumonias, who initially presented with increasing somnolence and hypoxic respiratory failure. this was felt to be secondary to mrsa pneumonia which was treated with a course of vancomycin and klebsiella uti which was treated with zosyn. he responded well to antibiotic therapy and was weaned off ventilatory support. however, he subsequently re-developed hypoxic respiratory failure. the cause of this second episode was felt to be multi-factorial from aspiration pneumonia, pulmonary edema, de-recruitment of alveoli given body habitus and developement of a new right pleural effusion. he was treated with an 8 day course of meropenem for ventilator associated pneumonia and he was diuresed to improve his pulmonary edema. recruitment maneuvers, including intermittent aprv ventilation, were used to bridge him through hypoxic episodes. in addition, intervential pulmonary re-positioned his trach on after it was found to be obstructed against the posterior wall of his trachea. . a brief hospital course by problem is also outlined below: . 1. hypoxic respiratory failure: initially admitted for hypoxic respiratory failure with evidence of pneumonia on cxr with associated fever and leukocytosis. sputum culture revealed evidence of mrsa in addition to pseudomonas (s to zosyn), and he was treated with a 10 day course of vanco/zosyn with good resolution of hypoxia. he was weaned off ventilatory support and was doing well on trach collar whe he developed a subsequent episode of hypoxia, with oxygen saturation transiently in the 60's, improved with bag-mask ventilation and placement back on the ventilator. this second episode was thought to be multifactorial. he had evidence of aspiration pneumonitis/pneumonia clinically and radiographically and he was initially continued on vancomycin and zosyn as above. after completion of this course of antibiotics he continued to demonstrate hypoxia. therefore repeat sputum culture was performed which also demonstrated citrobacter organism that was resistant to zosyn, but sensitive to meropenem. given his worsening clinical condition he was additionall treated with a course of meropenem antibiotics. secondly, he had evidence of pulmonary edema on cxr which was felt to be contributing to his respiratory distress. therefore he was diuresed initially with a lasix drip and then daily boluses iv. he diuresed well, over 1l negative per day. over this hospital course he had also inadvertantly pulled out his trach and it was replaced emergently with #6. he did well with this new trach, however did have one episode of acute obstruction on where it was found to be lodged against the posterior wall of the trachea, causing near 80% obstruction of air flow. this was re-positioned by interventional pulmonary with subsequent resolution of flow. lastly, he also developed an increasing r pleural effusion, suspected secondary to chf. a right sided thorocentesis was performed with drainage of 1500cc. the fluid was c/w a parapneumonic effusion. of importance, he also had lower extremity non-invasive ultrasounds to r/o dvt, which were negative, helping to argue against pulmonary embolism. however due to size he was not able to undergo ct angiogram and v/q scan was felt to be sub-optimal as well, especially while on the ventilator. it was felt that the other on-going issues, as described above, were more likely the cause of his acute hypoxic episodes and therefore he was not anti-coagulated with heparin. his most recent cxrs have been c/w pulmonary edema and bilateral pleural effusions. he has diuresed well with lasix 80mg iv qd making him negative >1l per day. his oxygenation has improved with weaning of his vent settings. on discharge he was on ps , fio2 of 50%. this should continue to be weaned as he becomes more euvolemic with diuresis. . it is also important to note that his hypoxic episodes were often concurrent with a large component of anxiety. in fact his anxiety was difficult to treat throughout his hospital course. while it was not likely completely causative of his hypoxia, it certainly exacerbated this acute episodes. he was placed on standing clonazepam, which he took as outpatient. in addition, he was given prn doses of zyprexa and evening trazadone. . 2. somnolence: he initially presented very somnolent, minimally responsive to sternal rub and not able to follow commands. this was felt to be a mixed picture from hypercarbia, infection (pneumonia, uti) and hypoxia. abg w/ co2 at 65. he had improvement of his mental status after correcting his hypercarbia/hypoxia and treating underlying infectious processes. upon improvement of his mental status he was found to have no focal neurologic deficits. although he had intermittent episodes of lethargy in the setting of oversedation (particularly after morphine), he was largely awake and alert for the remainder of his hospital course. . 3. hyperkalemia: initially hyperkalemic, with potassium of 7. likely exacerbated by acidemia and acute renal failure. this was treated aggressively with d50, insulin, calcium, kayexalate, and bicarbonate. in addition, the hypercarbic component was corrected through controlled ventilation. ekg demonstrated no peaked t's or interval widening throughout and he had no dysrythmia on telemetry monitoring. potassium subsequently normalized and was not an issue the remainder of his hospital course . 4. arf: 2.6 on admission, which was up from 0.9 1 year prior. bun also elevated, with pre-renal physiology (fena =0.3%, bun:cr ratio >20). no evidence of atn by urine sediment. he was initially treated aggressively with iv fluid repletion. nephrotoxic agents were held and medications were renally dosed. creatinine subsequently improved to 1.0-1.1. he had a second episode of arf to 2.0 during his hospital course which subsequently improved to 1.4 on discharge with diuresis . 5. troponin leak: max troponin 0.09 (upper limit <0.10) with flat ck/mb. he also had non-specific st changes by ekg without any acute ischemic changes. he was continued on asa, statin, b-blocker. heparin was held as he never had evidence of acute coronary syndrome. . 6. hypotension/sirs: early sepsis (distributive) vs hypovolemic hypotension on admission. sirs criteria including tachypnea, leukocytosis of 16,000. lactate was 2.4 on admission and systolic blood pressure improved after 3 liter ns ivf. he was transiently placed on low dose pressors with levophed to maintain map >65, with lactate rising to a peak of 4.8. pressors were weaned off after adequate ivf repletion and lacate normalized. suspected sourse of infection included pneumonia and uti. importantly, blood cultures remained negative throughout. his blood pressure remained wnl during the rest of his hospital stay. his labetolol and captopril were added back to his antihypertensive regimen. . 7. anemia of chronic disease: baseline hematocirt appears to be around 29, which is where he was at on admission. there was a spurious level of 12 on admission, however repeat checks did not corroborate this level. he had no signs of active bleeding and hematocrit remained stable, although fluctuated from 22-26, seeming to correlate with volume status. iron studies were checked and were felt to be consistent with anemia of chronic disease. he was started on iron on this hospital stay. he was placed on epo for 1 week until his creatinine improved and then it was d/c'd. he was guiac negative. . 8. dm2: initially placed on insulin drip for tight glycemic control. he was subsequently re-started on glargine with sliding scale insulin for breakthrough control. on admission he was on 44 units . this was adjusted based on blood glucose levels as needed recommendations. hi insulin was titrated up to glargine 60 u with ssi qid . 9. hypertension: systolic blood pressures were noted as high as 200's-220's. often in the setting of anxiety, however it was also suspected that he also had a component of difficult to control essential hypertension. his blood pressure medications were titrated up, with bp's subsequently controlled in 100's-110's. initially he was on metoprolol, but his was changed to standing labetolol with good effect. his bp was controlled on labetolol and captopril . 10. emesis: transient nausea, vomiting for 1 day, thought to be secondary to gastroparesis, exacerbated from recent hyperglycemia. he was placed on iv reglan w/ improved nausea. erythromycin also used transiently, then stopped because of new rash. reglan was then titrated off as pt was not having any residuals from his tf. . 11. nutrtion: during most of his hospital course, pt received tf from an ngt. his prior peg had been d/c'd before admission as pt was tolerating pos. nutrition was consulted and he had a video swallow test on ps , 50% with no signs of aspiration on direct visualization. he can tolerate a full diet. . 12. id: pt has grown multiple resistant organisms from his sputum including mrsa, pseudomonas, citrobacter and acinetobacter. he was treated with a course of vanco/zosyn and then meropenem for a vap. on discharge, he had scant sputum, was afebrile and showed no signs of focal infiltrates on cxr. he also has grown resistant klebsiella from his urine which was treated. he recently had a negative ua with a ucx growing g-rods thought to be a colonizer as he was afebrile without an elevated wbc. his foley was changed on . on , vancomycin was started for a 7 day course for a rle cellulitis. a vancomycin trough should be checked before his evening dose and dose adjusted accordingly. his cellulitis looked improved on d/c. . 13. code status: full code . 14. contact and hcp: brother . 15. ppx: heparin sc tid, ppi, bowel regimen, hob elevated > 30, peridex oral care . 16. access: midline placed by ir on medications on admission: paxil 40mg 9am, 5pm trazadone 100mg qhs prn mom 30cc prn vicodin q 4 prn apap 650mg q4 prn klonopin 0.5mg prn fs qid: ss humalog lopressor 75mg 9 am , 9pm flonase 2 spray prn senna 2 tabs prn neurontin 600mg 6am, 2pm, 10pm pulmocort 1 puff by mouth 9am,9pm heparin sq tid reglan 10mg qid albuterol/atrovent by mouth qid lantus 44 units sc qam, qhs humalog ss discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 3. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 250 mg/5 ml solution sig: three hundred (300) mg po q12h (every 12 hours). 5. paroxetine hcl 20 mg tablet sig: two (2) tablet po daily (daily). 6. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4-6h (every 4 to 6 hours) as needed. 7. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane tid (3 times a day). 8. nitroglycerin 0.4 mg tablet, sublingual sig: tablet, sublinguals sublingual prn (as needed) as needed for chest pain. 9. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 10. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 12. fluticasone 110 mcg/actuation aerosol sig: eight (8) puff inhalation (2 times a day). 13. ipratropium bromide 17 mcg/actuation aerosol sig: 8-10 puffs inhalation qid (4 times a day). 14. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) ml po daily (daily). 15. olanzapine 5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. 16. labetalol 300 mg tablet sig: one (1) tablet po tid (3 times a day): hold if sbp<100, pulse<55. 17. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 18. clonazepam 1 mg tablet sig: three (3) tablet po bid (2 times a day). 19. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 20. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 21. captopril 25 mg tablet sig: three (3) tablet po tid (3 times a day): hold if sbp<90. 22. heparin lock flush (porcine) 100 unit/ml syringe sig: ten (10) ml intravenous daily (daily) as needed. 23. prochlorperazine edisylate 5 mg/ml solution sig: ten (10) mg injection q6h (every 6 hours) as needed. 24. lorazepam 2 mg/ml syringe sig: 1-2 mg injection q4h (every 4 hours) as needed. 25. furosemide 10 mg/ml solution sig: eighty (80) mg injection daily (daily). 26. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 7 days. 27. insulin glargine 100 unit/ml cartridge sig: sixty (60) units subcutaneous twice a day: see additional sliding scale order. 28. humalog 100 unit/ml cartridge sig: as dir units subcutaneous four times a day: sliding scale fs<60 give oj, md fs61-120 mg/dl: 0 units 121-160 mg/dl: 2 units 161-200 mg/dl 4 201-240 mg/dl 6 241-280 mg/dl 8 281-320 mg/dl 10 321-360 mg/dl 12 361-400 mg/dl 14 >400 md. 29. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day). discharge disposition: extended care facility: & rehab center - discharge diagnosis: pneumonia obstructive sleep apnea diabetes type 2 copd urinary tract infection anemia acute renal failure peripheral vascular disease diastolic chf discharge condition: stable discharge instructions: please check vanco level before next dose () please check electrolytes qod and replete lytes as needed check hematocrit two times a week and more often if falling from in hospital value to hct 22.8. transfuse if <21 followup instructions: please follow up with dr. within 2 weeks procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances injection or infusion of thrombolytic agent thoracentesis thoracentesis arterial catheterization insertion of other (naso-)gastric tube bronchoscopy through artificial stoma bronchoscopy through artificial stoma transfusion of packed cells replacement of tracheostomy tube replacement of tracheostomy tube diagnoses: acidosis hyperpotassemia anemia of other chronic disease obstructive sleep apnea (adult)(pediatric) urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site acute kidney failure, unspecified unspecified septicemia severe sepsis chronic airway obstruction, not elsewhere classified infection with microorganisms resistant to penicillins diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled anxiety state, unspecified acute respiratory failure pneumonitis due to inhalation of food or vomitus cellulitis and abscess of leg, except foot alkalosis personal history of other diseases of circulatory system long-term (current) use of insulin infection with microorganisms without mention of resistance to multiple drugs morbid obesity osteoarthrosis, unspecified whether generalized or localized, site unspecified methicillin susceptible pneumonia due to staphylococcus aureus hypoxemia dehydration pulmonary congestion and hypostasis other and unspecified complications of medical care, not elsewhere classified atherosclerosis of native arteries of the extremities, unspecified diastolic heart failure, unspecified below knee amputation status gastroparesis pain in joint, shoulder region colostomy status other testicular hypofunction dependence on respirator, status mechanical complication of tracheostomy 

Answer: The patient is high likely exposed to