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: neurontin attending: chief complaint: lethargy major surgical or invasive procedure: pigtail drain placement history of present illness: 84 year old with h/o cad s/p cabg, esrd on hemodialysis presenting with three days of increasing lethargy, fever, decreased po intake, and llq pain. patient went to hd today and since complained of severe abdominal and back pain and he decided to come to the ed. he is a poor historian and states he cannot describe this pain further but does state it was gradual in onset started a couple of days prior to presentation. he denies chest pain, sob, fevers, chills, n/v, change in bowels, black, tarry, bloody stools, or dysuria. . in the ed, initial vs: 101.2 70 107/53 18 99% ra. he notably became tachycardic to the 120s and question of atrial fibrillation. reportedly makes urine, however no urine on straight cath. labs notable for lactate of 3.9 that decreased to 1.7 after 3 liters ivfs. wbc 20.1 with 5% bands. trop elevated to 0.21 with flat cks. cxr showed left peri-hilar opacity c/f pna. patient became hypotensive to the 70s while in ed and a triple lumen subclavian was placed and levophed started. currently at 0.09. he was given vancomycin and zosyn for presumed pna. due to llq pain, a ct abdomen/pelvis was performed and para-cholecystic inflammation can't rule out cholecystitis, sigmoid diverticulitis. transplant surgery was consulted and did not feel any surgical intervention was needed. vs prior to transfer: 76 8 97% 3l 130/65 on 0.09 mcs/kg/min of levophed. prior to transfer, small amount of hemoptysis was noted. . upon arrival to the micu, patient feels well without abdominal pain. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: past medical history: recent gi bleed earlier this month -> upper endoscopy showed only a hiatal hernia and colonoscopy showed extensive diverticulosis but no source of bleeding was identified peripheral vascular disease type ii diabetes mellitus esrd with hemodialysis hyperlipidemia mi ( and ) tia mrsa (+) (nares, ) enterobacteriaceae, stenotrophomonas maltophilia, and enterococcus faecalis bacteremia secondary to hd line infection . past surgical history: right fem-bk cabg x 4 peg (later removed) partial colectomy left cea right cea aortobifem and ventral hernia repair right toe amputations right inguinal hernia repair left ue av graft (thrombectomy of graft and ) left toe amputation right toe amputation peg (removed ) left cfa to ak- bypass with 8mm ptfe right hemiarthroplasty & orif social history: married, retired police officer, smokes cigarettes/day when home; denies etoh and other drug use. family history: non-contributory physical exam: admission: general: alert, oriented, no acute distress, cachectic appearing heent: sclera anicteric, mildly dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: decreased breath sounds at bases, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema, multiple toe amputations bilaterally . discharge: o: 98.8, 136/78, 76, 22, 95% on ra gen: awake, oriented x 2, nad, but in pain heent: very dry mm cv: rrr, + sem loudest at llsb pulm: poor inspiratory effort, mostly clear, lower fields with bs abd: scaphoid, non-tender, no rebound or guarding ext: warm, + pitting edema at l ankle, + toe amputations pertinent results: admission: 07:00pm blood wbc-20.1*# rbc-3.62* hgb-12.0* hct-36.0* mcv-99* mch-33.3* mchc-33.5 rdw-16.7* plt ct-138* neuts-87* bands-5 lymphs-3* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:00pm blood pt-13.2 ptt-27.2 inr(pt)-1.1 07:00pm blood glucose-124* urean-24* creat-2.4*# na-140 k-3.6 cl-92* hco3-35* 07:00pm blood alt-19 ast-33 ck(cpk)-65 alkphos-104 totbili-0.8 07:14pm blood lactate-3.9* . discharge: 08:20am blood wbc-16.2* rbc-2.24* hgb-7.5* hct-23.3* mcv-104* mch-33.2* mchc-32.1 rdw-16.7* plt ct-385 08:20am blood glucose-82 urean-18 creat-2.5* na-139 k-4.6 cl-101 hco3-28 angap-15 07:15am blood alt-14 ast-30 ld(ldh)-296* alkphos-118 totbili-0.2 08:20am blood calcium-8.4 phos-4.7* mg-2.0 11:16pm blood lactate-1.7 . studies: cxr : markedly limited study due to positioning. there is suggestion of a possible left perihilar opacity. correlate clinically. if indicated, consider repeat exam. . line placement : 1. new left central line ends at the level of the mid svc. no pneumothorax. 2. left basal opacity, concerning for pneumonia. . ctap : impression: 1. bilateral small pleural effusions with basal consolidations, concerning for pneumonia especially in the right lower lobe. 2. no drainable intra-abdominal abscess seen. assessment of the sigmoid colon is limited by extensive streak artifacts from the prosthesis and lack of luminal contrast. if further imaging is needed, a ct pelvis with rectal contrast may be helpful. 3. distended gallbladder, and a small amount of pericholecystic fluid. this could be secondary to n.p.o. status; however, if there is clinical concern for acute cholecystitis, an ultrasound can be obtained for further evaluation. 4. extensive atherosclerotic disease of the aorta with narrowing of the origins of the sma, celiac and renal arteries. . ruq u/s : findings: the gallbladder is moderately distended, with a small amount of layering sludge and two tiny echogenic gallstones. corresponding to the abnormality seen in the prior ct study, there is a focal hypoechoic striated area along the anterior wall of the gallbladder, which may represent focal wall thickening. there was no sign of the time of the study. the common bile duct measures 4 mm and is normal. if there is concern for acute cholecystitis, a hida scan or a repeat ultrasound can be obtained for further evaluation. . gallbladder scan: normal filling of the gallbladder and emptying into the small bowel after cck administration. . tte: no obvious vegetations seen. normal global and regional systolic function. mild calcific aortic stenosis. mild mitral regurgitation. mild pulmonary hypertension. . cxr: incomplete left pleural drainage may be a function of catheter placement anterior to posterior pleural collection, loculated or not. left pleural thickening may be restrictive, responsible in part for continued left lower lobe atelectasis. severe worsening right lower lobe atelectasis. . ct chest: 1. moderate bilateral exudative pleural effusions, layering on the right, partially loculated on the left, despite a left pleural drain. 2. severe bilateral lower lobe atelectasis, without evidence of bronchial obstruction. degree of visceral pleural thickening is indeterminate surrounding the largely collapsed left lower lobe, but not appreciable along the left upper lobe or the parietal pleura in the left chest. 3. severe atherosclerotic plaque and mural thrombus in fusiform dilated descending thoracic aorta. 4. diffuse lower esophageal wall thickening, probably esophagitis. . : following removal of a left pigtail pleural catheter, a large loculated left pleural fluid collection has slightly increased in size. there is no visible pneumothorax. exam is otherwise similar in appearance to the recent study except for worsening opacity at the right base with persistent adjacent small right pleural effusion. . cxr: as compared to the previous radiograph, the extensive left pleural effusion is unchanged in extent. the effusion on the right has slightly decreased, there is improved ventilation of the right lung. unchanged size of the cardiac silhouette. unchanged bilateral basal areas of atelectasis. no newly-appeared focal parenchymal opacities suggesting pneumonia. . micro: 7:14 pm blood culture **final report ** blood culture, routine (final ): streptococcus pneumoniae. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ streptococcus pneumoniae | ceftriaxone----------- 1 s erythromycin---------- =>1 r levofloxacin---------- <=0.5 s meropenem------------- 0.5 i penicillin g---------- 4 i tetracycline---------- =>16 r trimethoprim/sulfa---- 8 r vancomycin------------ <=1 s anaerobic bottle gram stain (final ): reported to and read back by @ 1:10 pm on . gram positive cocci in pairs and chains. aerobic bottle gram stain (final ): gram positive cocci in pairs and chains. . 12:43pm pleural wbc-5750* rbc-3525* polys-97* lymphs-1* monos-0 eos-2* totprot-2.8 glucose-6 ld(ldh)-5058 . cytology of pleural fluid: negative for malignant cells . 10:10pm urine blood-neg nitrite-neg protein-100 glucose-150 ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 10:10pm urine rbc-1 wbc-2 bacteri-none yeast-none epi-0 10:10pm urine casthy-1* urine culture (final ): yeast. <10,000 organisms/ml. brief hospital course: hospital course: pt is a 84 year old m with multiple medical problems presenting with three days of increased lethargy and found to be in septic shock. source most likely pneumonia. pt was started on vanc/zosyn. blood cultures grew gpc's, which speciated to strep pneumoniae. he initially required levophed for bp support. he was eventually transferred to the floor for further management (addressed below). ultimately, a meeting was held to discuss goals of care, the patient was transitioned to comfort-focused measures and went home with hospice services. . # septic shock: fever, leukocytosis, and hypotension on presentation to micu. possible sources included pna vs. colitis vs. cholecystitis. pt had cxr suggestive of possible consolidation, which was further supported by ct a/p. regarding other sources, ct a/p showed no intrabdominal abscess, but some pericholecystic fluid. ruq demonstrated edema, but patient had a negative sign and lft's were normal. he was placed on vanc/zosyn for broad coverage, and started on levophed. blood cultures grew gpc's in pairs & chains. surgery was consulted given concern for cholecystitis; however, he clinically did not appear to have cholecystitis and no surgery was indicated. additionally, hida was negative. blood cultures speciated to s. pneumonia. antibiotics were narrowed to ceftriaxone. levophed was weaned off and the patient was transferred to the floor. . # pneumonia complicated by empyema: repeat cxr revealed a loculated pleural effusion and interventional pulmonology was consulted for drainage. a pigtail catheter was placed and studies revealed an empyema. gram stain and cultures were negative (note, patient had received many days of broad antibiotics at this time). thoracic surgery was consulted for consideration of vats/decortication; however, given his multiple medical comorbidities, a more conservative approach was attempted. the patient received 4 days of tpa injected into his drain to help break up the loculations and promote drainage of the effusion. his oxygen requirement improved and leukocytosis initially trended down. unfortunately, his effusion reaccumulated after the catheter was pulled. his leukocytosis began to rise and he became increasingly delerious. other infectious work-up was negative. given the likelihood of complications of an additional operative procedure to drain the effusion, and the patient's stated desire to focus on quality of life, a family meeting was held to discuss options and all agreed it was best to focus goals of care to comfort measures. . # esrd on hd: on m/w/f schedule, which continued while inpatient. renal was consulted and provided recommendations. meds were renally dosed. he was continued on sevelemer, nephrocaps, and zemplar with hd. given the change in goals of care, the patient decided to go home with hospice and discontinue hemodialysis. . # cad: s/p cabg () and peripheral vascular disease s/p stents. continued on statin. asa was initially held given hemoptysis (secondary to pna), but restarted on hod#1. metoprolol was initially held in setting of sepsis, then restarted once hemodynamically stable. plavix was held initially and then restarted as well. given his change in goals of care, these medications were discontinued at discharge. . # diabetes: insulin dependent. hiss with qachs finger sticks was provided. he required very little coverage. given his change in goals of care, this was discontinued at discharge. . # recent gi bleed: noted on prior admission. patient did not want extensive work up. continued on pantoprazole while in house and his hct remained stable. . # goals of care: patient stated clearly that he wished to be dnr/dni. he also wished to focus on pain control. palliative care was consulted for recommendations. he was re-started on oxycontin 10 mg for basal pain control. when the decision regarding the need for surgical intervention was discussed with the patient and his family they decided to change goals of care to focusing on aggressive management of his symptoms. he was discharged with home hospice services. medications on admission: docusate sodium 100 mg senna 8.6 mgqhs polyethylene glycol daily calcium carbonate 200 mg tid aspirin 81 mg daily acetaminophen 325 mg qid pantoprazole 40 mg q12 simvastatin 80 mg daily zinc sulfate 220 mg daily calcitriol 0.25 mcg daily b complex-vitamin c-folic acid 1 mg daily sevelamer carbonate 800 mg tid trazodone 50 mg qhs oxycodone 5 mg q4:prn multivitamin daily insulin lispro sliding scale metoprolol tartrate 25 mg twice a day. nephrocaps discharge medications: 1. hospice please screen and admit to hospice 2. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 4. polyethylene glycol 3350 17 gram/dose powder : one (1) dose po daily (daily) as needed for constipation. disp:*20 qs* refills:*0* 5. zofran odt 4 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po every six (6) hours as needed for nausea. disp:*30 tablet, rapid dissolve(s)* refills:*0* 6. morphine concentrate 100 mg/5 ml (20 mg/ml) solution : 5-15 mg po every four (4) hours as needed for moderate to severe pain or shortness of breath. disp:*30 cc* refills:*0* 7. lorazepam 2 mg/ml concentrate : 0.5-2 mg po every six (6) hours as needed for anxiety. disp:*30 cc* refills:*0* 8. haloperidol lactate 2 mg/ml concentrate : one (1) mg po every six (6) hours as needed for relief of agitation. disp:*30 cc* refills:*0* 9. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain/fever. disp:*60 tablet(s)* refills:*0* 10. oxycodone 10 mg tablet extended release 12 hr : one (1) tablet extended release 12 hr po q12h (every 12 hours). disp:*60 tablet extended release 12 hr(s)* refills:*0* discharge disposition: home with service facility: hospice discharge diagnosis: pneumonia and empyema pneumoncoccal bacteremia and septic shock end stage renal disease coronary artery disease peripheral vascular disease discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: dear mr. , you were admitted to medicine service for evaluation of pain and lethargy. you were found to have a pneumonia, a pleural effusion (fluid around your lungs), and bacteria in your blood. you initially spent time in the icu then were transferred to the regular floor. you had a drain placed by interventional pulmonology to remove the fluid and the thoracic surgeons also helped with the management. the drain was not successful, and the thoracic surgeons ultimately recommended surgery. we had a family meeting and decided to focus our goals of care to comfort-oriented care, focusing on control of your pain and any other symptoms that may be bothering you. . we are making a few simplifications to your current medication regimen. you may change these as needed and per your wishes. followup instructions: a hospice nurse will be following up with you. please contact him or her with any questions. procedure: venous catheterization, not elsewhere classified hemodialysis injection or infusion of thrombolytic agent diagnoses: pneumonia, organism unspecified end stage renal disease renal dialysis status coronary atherosclerosis of native coronary artery diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis aortocoronary bypass status other and unspecified hyperlipidemia septic shock pneumococcal septicemia [streptococcus pneumoniae septicemia] empyema without mention of fistula diverticulitis of colon (without mention of hemorrhage) 

Answer: The patient is high likely exposed to