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: colchicine / tramadol / vicodin / ultram attending: chief complaint: r toe ulcer major surgical or invasive procedure: r leg angiography history of present illness: 79 y.o. with pvd, a.fib (on coumadin), r leg neuropathy (no longer ambulatory) who was referred from podiatrist (dr. for second r toe infection. she has developed right foot problems that foot swelling, redness, heel ulcer, ulceration of second toe and ulcer of great toe. as per report, ekg shows a.fib. with hr 79. lvh with l strain pattern, twi inversions. she had mri at nebh which showed r second toe ulcer, but no evidence of osteomyelitis, but found to have sfa disease. dr. would like to have peripheral angiography. given that inr 3.0 yesterday, she received vitamin k. . upon admission to floor: 98.4 bp:109/80 hr80 18 90%ra on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. past medical history: -pvd -small r toe ulcer -a.fib on coumadin -osteopenia -neuropathy (inability to walk for 18 yrs and the exact etiology is unclear) -asthma -copd -vitamin b12 deficiency with pernicious anemia -hepatitis b -urine vre -b/l ankle edema -gerd -chf -acute cholangitis (no surgical intervention) -left hip replacement -l ankle orif - hx ghon complex on cxr in the past, multiple tuberculosis workups per pt social history: -tobacco history: 90 pack year smoking (quit 5/). previous etoh use (14 drinks/week quit 5/). iv, illicit, herbal drug use: none. residence: lives alone, has caretaker, daughter in occupation: retired, used to work at equestrian shows, some exposure in the remote past to horse stables pets: none travel: recent travel to springs, ny for a horse show, has never left the united states. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: upon admission: =================================== vs: t=98.4 bp:109/80 hr80 18 90%ra general: oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of *** cm. cardiac: , normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: diffuse erythematus macular rash covering her back. no stasis dermatitis, scars, or xanthomas. 2cmx3cm r stage 3 pressure ulcer, r second toe ulcer pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ upon discharge: ======================================= physical examination: vs: 98.0 - 106/82 - p80 - 18 - 93 ra - i/o: 200/800, yest 1270/700+ + bm yest. (98-130/35-82), ? <-- 68.2 gen: in bed, alert, oriented, lying uncomfortably. heent: no pallor,no jaundice or cyanosis, mmm neck: supple, with non-elevated jvp. cardiac: rrr, normal s1, s2. no m/r/g. lungs: cta, wheezing bilateral lung fields abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. toes with small scabs, taped up circumferentially skin: rash improved neuro: cn 2-12 normal, strength 5/5 upper extremities. pertinent results: upon admission: ================================== 06:55pm blood wbc-10.7 rbc-3.63* hgb-11.0* hct-35.0* mcv-97 mch-30.4 mchc-31.4 rdw-14.8 plt ct-290 06:10am blood glucose-80 urean-22* creat-0.9 na-139 k-4.7 cl-100 hco3-31 angap-13 06:10am blood calcium-8.8 phos-4.2 mg-1.9 cholest-203* 06:10am blood triglyc-146 hdl-56 chol/hd-3.6 ldlcalc-118 . upon discharge: =================================== 06:36am blood wbc-4.3 rbc-3.17* hgb-9.7* hct-31.2* mcv-98 mch-30.6 mchc-31.2 rdw-15.2 plt ct-315 06:36am blood pt-22.5* inr(pt)-2.1* 06:36am blood glucose-74 urean-14 creat-0.4 na-138 k-4.3 cl-101 hco3-32 angap-9 06:36am blood calcium-8.1* phos-2.9 mg-2.0 . venous ue ultrasound impression: 1. patent right and left basilic veins and cephalic vein in the forearm. 2. thrombus seen within the distal left cephalic vein. . venous le ultrasound impression: patent greater and lesser saphenous veins bilaterally. . cardiac echo: lvef 70% the left atrium is markedly dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef 70%). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. . ct abd/pelvis, chest without contrast: impression: 1. right upper lobe consolidation, concerning for pneumonia, with small foci of peribronchovascular consolidation in the left upper lobe, which could represent atelectasis or atypical infection. 2. fluid layering in the presacral space, of indeterminate etiology. 3. no ct evidence for hematoma. 4. extremely dense, diffusely distributed arterial calcifications, including the coronary arteries and aortic valve, of indeterminate hemodynamic significance. 5. t9 vertebra plana with retropulsion into the spinal canal, age indeterminate in the absence of prior imaging. mri is recommended for evaluation of intrathecal structures if clinically indicated. . cta chest w&w/o c&recon impression: 1. no evidence of acute pulmonary thromboembolic disease in the central or subsegmental branches. tiny focus of linear hypoattenuation in the right lower lobe pulmonary arterial branch may represent sequelae of a tiny chronic pulmonary embolus. findings of pulmonary arterial hypertension. there is mild straightening of the interventricular septum and right ventricular enlargement which correlates with reported right ventricular strain. cardiomegaly with left atrial enlargement. 2. bilateral upper lobe patchy consolidation is likely related to infectious/inflammatory process. recommend followup unenhanced ct chest six to eight weeks following the initiation of antibiotic therapy to document resolution. 3. upper lobe predominant centrilobular emphysema. 4. small bilateral pleural effusions. 5. interlobular septal thickening, although a nonspecific findings, with cardiomegaly and bilateral pleural effusions, pulmonary edema is considered the likely etiology. 6. minimally enlarged right paratracheal lymph node, likely reactive. attention to this finding on followup imaging. 7. t8 vertebra plana compression fracture of indeterminate age with retropulsion and mild narrowing of the spinal canal. further evaluation can be obtained with mri. . cxr (during episode of hypotension) right ij catheter tip is at the cavoatrial junction. cardiomegaly is unchanged. small bilateral pleural effusions, left greater than right, with adjacent atelectasis and right upper lobe consolidation are unchanged. patient has known emphysema. . cxr findings: there has been interval removal of a right internal jugular venous central line. the cardiac and mediastinal silhouettes are stable as well as the right upper lobe changes. moderate pulmonary vascular congestion is also stable. impression: stable chest radiograph. . microbiology/immunological results - 11:32 urine histoplasma antigen-- pnd - immunoglobulin e 1408 h <or=114 /l - aspergillus/galactomannan antigen 0.1 <0.5 - strongyloides antibody, igg () strongyloides igg <1.00 <1.00 - fungitell (tm) assay for (1,3)-b-d-glucans results reference ranges ------- ---------------- >500 pg/ml* negative less than 60 pg/ml indeterminate 60 - 79 pg/ml positive greater than or equal to 80 pg/ml retested value : 5099 pg/ml - hcv ab: pending. - hiv ab: pending. - anca 05:13 negative b1 hepatitis hbsag hbsab hbcab igm hav 05:36 pnd pnd pnd pnd other labs calcium freeca 05:52 1.12 pth 218* cortisol 13.91 25vitd 14* lipid/cholesterol cholest triglyc hdl chol/hd ldlcalc 06:10 203* 1461 56 3.6 118 enzymes & bilirubin alt 8 ast 23 alkphos 52 tot bili 0.2 probnp 384 <-- 2192 cultures blood cultures (, , , 8.25.12,) negative, final urine culture () negative, final cath tip culture () negative, final mrsa screen negative urine culture (final ): yeast. >100,000 organisms/ml. stool negative for c. diff, neg fecal culture (neg enteric gnrs, neg salmonella, shigella, campy) 3:30 pm blood culture ( myco/f lytic bottle) blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. . 10:15 am sputum source: induced. gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci. in clusters. 1+ (<1 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. respiratory culture (final ): moderate growth commensal respiratory flora. fungal culture (preliminary): yeast. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): . 7:40 am sputum gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. acid fast culture (preliminary): acid fast smear (final ): reported to and read back by , and , @ 15:30, . acidfast bacilli. few seen on concentrated smear. fungal culture (preliminary): gram stain of this specimen indicates contamination with oropharyngeal secretions and invalidates results. specimen is only screened for cryptococcus species. new specimen is recommended. mtb direct amplification (final ): negative for m tuberculosis by naat. await culture results. naat performed by state laboratory , ma . . 10:55 am sputum site: induced please do culture for rhodococcus. gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. acid fast culture (preliminary): acid fast smear (final ): no acid fast bacilli seen on concentrated smear. fungal culture (preliminary): gram stain of this specimen indicates contamination with oropharyngeal secretions and invalidates results. specimen is only screened for cryptococcus species. new specimen is recommended. . 4:15 pm sputum source: induced. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): . 11:14 am blood culture ( myco/f lytic bottle) source: line-picc. blood/fungal culture (pending): blood/afb culture (pending): brief hospital course: 79f with pvd, afib, chf, copd, gerd on chronic prednisone 10mg daily (for copd) and neuropathy transferred here from nebh for rle angiogram, which revealed significant pvd. before intervention was performed, she became intermittently febrile and hypotensive. she was transferred to the icu on for management of presumed sepsis. no clear source of infection was identified, but presumed to be post-obstructive pneumonia as she has had pneumonias in similar areas in the past year. she was initially managed with cefepime and vancomycin, but cefepime was stopped due to concern for allergy. she was switched to meropenem and vancomycin (vancomycin was stopped ). she did not undergo bronchoscopy in accordance with her wishes (she also had a recent bronch hospital for rul opacity in , s/p bronchoscopy which revealed "diffuse mucus, cytology negative for malignancy" and also reportedly included fungal debris. her hypotension was managed with fluids in the icu, and she was transferred back to the cardiology service. on the cardiology service, she was on respiratory precautions for some time due to concern for m.tuberculosis (ruled out by 3 negative induced sputums and naat negative for m.tuberculosis). though she did experience some intermittent asymptomatic hypotension, she remained stable on the floor. she was seen by the pulmonary team and recommended for a 4 week course of antibiotics (can be changed to augmentin po as outpatient) as well as the infectious disease team for concern of fungal pneumonia. she was discharged on day 18 of her hospital course to rehab, in good condition and improved pulmonary condition. she will follow up with dr. as an outpatient regarding her peripheral vascular disease. . >> active issues . # sepsis: she had fever, leukocytosis, and hypotension. potential sources considered include lung, urine, bone, picc line infection (placed 2 weeks prior to presentation at osh), gi (though no c. diff symptoms), but no obvious source found. she was treated empirically with cefepime --> meropenem and vancomycin for concern of post-obstructive pneumonia. pulmonary team was consulted (due to upper lobe infiltrates, report of chronic ghon complex in old medical records) and suggested post-obstructive pneumonia as source of sepsis. they also suggested investigating alternative fungal sources of pneumonia (sputum stains and cultures sent and are pending). id was consulted and were investigating mycobacterial infection (non-tuberculosis). there was also concern for abpa, with elevated b-glucan and ige, which could be a possibility. - f/u pending cultures (see below) - f/u with ms. pulmonologist as an outpatient - f/u with id (dr. on ) . # hypotension: most likely to sepsis +/- hypovolemia. resolved in the icu with fluids, often occured after gentle diuresis for pulmonary edema. echo and chest cta did not demonstrate cardiogenic etiology or pe. ?of gi bleed contributing given positive guaiac and low hematocrit. morning cortisol was 25 which speaks against adrenal insufficiency. - please consider tenuous volume status when diuresing. . # anemia: slowly down trending hct throughout admission, though down-trend resolved. likely multifactorial from dilution, bone marrow supression in the setting of inflammation. positive guaiac but no major signs of bleeding. - should follow up + guaiac as an outpatient, likely requires colonoscopy . # eosinophilia: on admission, she had a rash suspicious for drug rash, and this was thought to be to either vicodin or ultram in osh. alternatively, micu team thought this was to cefepime and changed to meropenem. regardless, they have remained elevated throughout her hospitalization. strongyloides was negative. noted that she has had some hem/onc work-up in the past, could be investigated as an outpatient. please also see discussion for rul infiltrate. . # sob/desats: contributing factors may be pneumonia, atelectasis, copd as well as congestion d/t aggressive fluid resucitation. seems to be much improved now and stable though auscultation and cxr still suggest congestion - holding iv fluids for now, will consider duresis if resp status worsens. - o2 with sat goal 90-93% - continue levalbuterol nebs. - continue prednisone at 10mg daily for now, needs taper - continue fluticasone-solumedrol diskus - ? need for bactrim prophylaxis in the setting of chronic steroids. . # rul infiltrate: per osh where bronchoscopy was done, no microbiology was sent on specimes, cytology was neg for malignancy. in this patient on chronic steroids with bil ul infiltrates, there is concern for pulmonary fungal infection, abpa, or histoplasmosis. also concern for eosinophilic pneumonia process. negative for pneumocystic jiroveci. anca negative. very positive ige (1408). b-glucan very positive (5099), galactomannan not. - sputum x3 for afb + fungal cultures, nocardia, rhodococcus - needs outpatient follow-up - can consider bronchoscopy as an outpatient if functional status improves, and patient is willing. . # hyperkalemia: not an issue on discharge. max value of 6.6, with stable renal function and no recent k repletion. am cortisol level was adequate before, unlikely that this is adrenocortical insufficiency. could be trimethoprim-induced hyperkalemia or heparin-induced hyperkalemia (though very unusual). both were stopped and the hyperkalemia resolved. . # a.fib: rate controlled on metoprolol and digoxin. some bursting intermittently that resolved. coumadin held intermittently in house for possible procedures, was briefly maintained on hep gtt. chads2=2. . # pvd: wound care in house. - dr. will f/u as outpatient for sfa stent, though she may be a poor candidate for general anesthesia . # r toe ulcer: no evidence of osteomyelitis on mra at osh. on bactrim at rehab for concern for osteomyelitis, stopped in-house. on meropenem in house. continued wound care. . # rash: clinical appearance consistent with drug-induced rash (prior to abx regimen). per patient it is allergy to vicodin which she got at osh. could also be a concern for lymphoma w/ eosinophilia and itchy rash, but unlikely. - continued topical hydrocortisone cream (needs to be stopped as outpatient). . # urinary incontinence: chronic issue. no other symptoms or findings to suggest spinal cord or cauda equina issues. this is likely to her general deconditioning and prolonged foley, has happened to her in the past. - pt aware of pelvic floor exercises, reconsulted pt. . >> inactive issues: . # vitamin d deficiency: continued supplementation. . #gerd: continued omeprazole. . #copd: see sob above, continued symbicort, nebulizers. . # neuropathy with inability to walk: continued gabapentin, pt consult . >> transitional issues: . - incidental ct chest: "t9 vertebra plana with retropulsion into the spinal canal, age indeterminate in the absence of prior imaging. mri is recommended for evaluation of intrathecal structures if clinically indicated." . - bilateral upper lobe patchy consolidation is likely related to infectious/inflammatory process. recommend followup imaging: unenhanced ct chest six to eight weeks following the initiation of antibiotic therapy to document resolution (ie, one month from discharge). . - prednisone should be tapered as an outpatient by primary care doctor after finishing antibiotic course. . - needs to finish antibiotics for a 4 week course. started meropenem , is on day 15 on day of discharge. needs 2 more weeks (13 days), ends on augmentin (prescribed). . - she needs to stop hydrocortisone topical cream as an outpatient, please ensure she has done this. . - required a great deal of magnesium in house. need supplementation as an outpatient. . - pulm issue: elevated ige concerning for abpa. sent aspergillus antibody (ige) on day of dischrge. please follow this up. she may need follow up with an allergist/immunologist if this is positive for asp skin testing. will not treat with increased prednisone at this time as no results, but may need increase in prednisone as outpatient if concerned for apba. currently on 10mg prednisone daily for at least 2-3 weeks (alternatively, if no concern for abpa, needs prednisone taper, see above). . - pending studies: - urine histoplasma antigen - hepatitis panel and hep c, hiv - mycolytic blood cx - sputum fungal culture, acid fast culture - sputum fungal culture, acid fast culture, follow up of mycobacterium from state lab - sputum fungal culture, acid fast culture - sputum fungal culture (+yeast), acid fast culture medications on admission: preadmission medications listed are correct and complete. information was obtained from patient and webomr. 1. acidophilus-pectin *nf* (lactobacillus acidoph-pectin) 1 capsule oral 2. allopurinol 100 mg po daily 3. amlodipine 5 mg po daily , hold sbp<100 4. digoxin 0.125 mg po daily 5. duoneb *nf* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 ml inhalation q4h 6. ferrous sulfate 325 mg po daily 7. fleet enema 1 enema pr daily:prn constipation please hold >2bm/day 8. hydrocortisone cream 1% 1 appl tp tid 9. furosemide 20 mg po daily duration: 1 days please end on 10. metoprolol succinate xl 25 mg po daily hold sbp<100, hr<55 11. mucinex *nf* (guaifenesin) 600 mg oral 12. gabapentin 600 mg po bid 13. prednisone 10 mg po daily 14. omeprazole 20 mg po daily 15. symbicort *nf* (budesonide-formoterol) 160-4.5 mcg/actuation inhalation daily 16. thiamine 100 mg po daily 17. ascorbic acid 500 mg po daily 18. diazepam 5 mg po hs 19. sulfameth/trimethoprim ds 1 tab po bid 20. warfarin 2 mg po daily16 21. milk of magnesia 30 ml po daily:prn constipation 22. bisacodyl 5 mg po daily:prn constipation 23. lidocaine 5% patch 1 ptch td daily please apply one patch to shoulder. 24. tramadol (ultram) 50 mg po q6h:prn pain discharge medications: 1. ascorbic acid 500 mg po daily 2. bisacodyl 5 mg po daily:prn constipation 3. gabapentin 600 mg po bid 4. lidocaine 5% patch 1 ptch td daily please apply one patch to shoulder. 5. milk of magnesia 30 ml po daily:prn constipation 6. omeprazole 20 mg po daily 7. thiamine 100 mg po daily 8. amoxicillin-clavulanic acid 875 mg po q12h post-obstructive pneumonia duration: 13 days through 9. prednisone 10 mg po daily 10. digoxin 0.0625 mg po daily 11. warfarin 2 mg po daily16 12. diltiazem extended-release 180 mg po daily please hold for sbp<100 13. fluticasone-salmeterol diskus (250/50) 1 inh ih 14. simethicone 40-80 mg po qid:prn gas/bloating 15. acidophilus-pectin *nf* (lactobacillus acidoph-pectin) 1 capsule oral 16. fleet enema 1 enema pr daily:prn constipation please hold >2bm/day 17. ferrous sulfate 325 mg po daily 18. allopurinol 100 mg po daily 19. duoneb *nf* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 ml inhalation q4h 20. symbicort *nf* (budesonide-formoterol) 160-4.5 mcg/actuation inhalation daily 21. mucinex *nf* (guaifenesin) 600 mg oral 22. calcium carbonate 1000 mg po bid 23. ipratropium bromide neb 1 neb ih q6h:prn sob 24. nicotine patch 7 mg td daily 25. sarna lotion 1 appl tp tid:prn itching 26. vitamin d 50,000 unit po 1x/week (mo,tu) 27. diazepam 5 mg po hs 28. albuterol 0.083% neb soln 1 neb ih q6h:prn wheezing/sob 29. docusate sodium 100 mg po bid 30. acetaminophen 1000 mg po q6h:prn pain 31. hydrocortisone cream 1% 1 appl tp tid discharge disposition: extended care facility: care and rehab discharge diagnosis: primary care: r toe ischemic ulcer health care associated pneumonia / post-obstructive pneumonia sepsis secondary: peripheral vascular disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , it was a pleasure taking care of you here at . you went to from your rehab for the ulcers on your toe and heel that were not healing very well. you were transferred to to have an angiogram of your right leg that showed a lot of blockages in the arteries in your leg. before we were able to perform more tests, you had a fever and low blood pressures. since your chest x-ray showed a possible pneumonia, we treated you with antibiotics and transferred you to the icu for a brief amount of time but you were able to be transferred to the floor. some blood tests that showed you may have had a fungal infection in your lungs. you were briefly on respiratory precautions, but we have determined that you do not have tuberculosis. we still do think that you have a bacterial pneumonia, called "post-obstructive pneumonia," for which you should continue to take antibiotics (treatment duration per d/c summary). at this point it is difficult to tell whether you have a fungal infection in your lungs, but if you do, it is not a very acute infection and you do not need to be treated until the final results come back. while you were here, some changes were made to your medications. attached is an updated and accurate list. followup instructions: cardiology dr. please call to make a follow-up appointment with dr. for within 2-3 weeks of discharge. he plans to repeat your lower extremity angiography in ~3 weeks for your peripheral vascular disease. pulmonology sew- , md hospital pulmonology , ma ( ***please call to make a follow-up appointment for 1-2 weeks after discharge.*** infectious disease when: monday at 9:30 am with: , md building: lm bldg () campus: west best parking: garage primary care name: , a. location: bldg, address: , , phone: fax: please follow up with your primary care doctor after you are discharged from rehab. procedure: arteriography of femoral and other lower extremity arteries aortography central venous catheter placement with guidance diagnoses: hyperpotassemia anemia, unspecified esophageal reflux congestive heart failure, unspecified long-term (current) use of steroids unspecified septicemia atrial fibrillation acute on chronic diastolic heart failure personal history of tobacco use other opiates and related narcotics causing adverse effects in therapeutic use sepsis mononeuritis of lower limb, unspecified ulcer of other part of foot long-term (current) use of anticoagulants dermatitis due to drugs and medicines taken internally chronic obstructive asthma, unspecified pressure ulcer, heel hemorrhage of gastrointestinal tract, unspecified urinary incontinence, unspecified disorder of bone and cartilage, unspecified atherosclerosis of native arteries of the extremities with ulceration hip joint replacement unspecified vitamin d deficiency pressure ulcer, unspecified stage bacterial pneumonia, unspecified eosinophilia 

Answer: The patient is high likely exposed to