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: flagyl attending: chief complaint: declining mental status major surgical or invasive procedure: picc line placement *2 arterial line placement dialysis catheter placement-tunneled line *2 and temporary catheter *1 central venous line placement bronchoscopy history of present illness: 78 year old woman with history of multiple medical problems including type 2 diabetes mellitus, hypertension, obstructive sleep apnea s/p trach placement, and breast cancer being transferred from rehab macu for further evaluation. for the past 3 weeks, she has been progressively weak, somnalent, and hypercapnic. she had orginally ventilated just overnight, but has been on 24 hour ventillation for these 3 weeks. she continues to have chf on cxrs. at rehab, she was noted to have progressive delerium. she was reportedly independent in the months prior to admission, but now is persistantly somnilent arousing to minimal stimili. she has had a persistant c-diff infection requireing a rectal tube, and from which she has developed malnutrition with albumins in the 1.5-2 range. she was initially on tpn, but later had an ng placed. she is now on elemental feeds, with a plateau in her albumin. she has been found to be anasarcic malnutrition with skin breakdown. she also developed progressive renal failure, with a creatine rising to mid 2s. paliatitive care has been involved at hebreb, but her sister , who is hcp, continues to want everything done. she requested that her sister be transferred to the hospital to see if there's anything else that can be done for her. currently she is minimally responsive. review of systems: unable to obtain. past medical history: 1. hypertension 2. diabetes mellitus 3. breast cancer - infiltrating ductal carcinoma 4. obstructive sleep apnea - s/p tracheostomy 5. osteoarthritis 6. s/p multiple falls 7. congestive heart failure 8. atrial flutter 9. atrial septal defect 10. mitral regurgitation 11. cor pulmonale 12. s/p stroke 13. obesity 14. spinal stenosis 15. lower gi bleed social history: normally lives at home, but has been at rehab since last hospitalization. denies alcohol, drug or current tobacco use. per her sister, she is a former smoker, but unclear what her pack year smoking history is. family history: diabetes mellitus. physical exam: exam on admission: vitals: t 97.1 hr: 80 bp: 109/63 sat 97 on ac 450/12/45/5 gen: anasarcic, somnilent, understands that she is at heent: trach in place cv: rr, nl rate. quiet heart sounds. lungs: intubated, bilateral anterior breath sounds abd: obese, distended, tender to palpation. ext: no edema. 2+ dp pulses bl skin: palm breakdown, decubetous ulcers on back neuro: minimal response to stimuli, twitching of her foot. exam on discharge: vitals: t: 97.1 hr: bp: 117/48 rr: 19 sp02: 94% on cpap, pressure support: . gen: anasarcic, alert, able to mouth responses to questions. heent: trach in place cv: rr, nl rate. quiet heart sounds. lungs: intubated, coarse bilateral anterior breath sounds abd: obese, distended, non tender to palpitation, bowel sounds. ext: no edema. 2+ dp pulses bl neuro: responds to stimuli, moves all extremities. pertinent results: labs on admission: wbc-9.2 rbc-2.86* hgb-8.0* hct-26.7* mcv-93 rdw-18.7* plt ct-239 neuts-85.3* bands-0 lymphs-11.0* monos-3.3 eos-0.2 baso-0.1 pt-17.9* ptt-33.7 inr(pt)-1.6* glucose-134* urean-85* creat-1.9* na-145 k-5.1 cl-105 hco3-32 angap-13 alt-32 ast-66* ld(ldh)-274* alkphos-114 totbili-0.2 probnp-* totprot-5.8* albumin-2.4* globuln-3.4 lactate-1.1 type-art rates- tidal v-450 peep-5 fio2-50 po2-67* pco2-59* ph-7.35 caltco2-34* base xs-4 other labs: wbc-18.0* rbc-2.35* hgb-6.9* hct-22.4* mcv-95 rdw-23.1* plt ct-221 06:57pm blood ck-mb-10 mb indx-8.8* ctropnt-0.62* 03:45am blood ck-mb-notdone ctropnt-0.61* 11:47am blood ck-mb-notdone ctropnt-0.76* caltibc-191* ferritn-178* trf-147* hapto-<20* tsh-2.6 cortsol-23.0* labs on discharge: 03:16am blood wbc-9.8 rbc-3.01* hgb-8.8* hct-29.5* mcv-98 mch-29.2 mchc-29.8* rdw-18.4* plt ct-230 03:16am blood pt-15.2* ptt-32.3 inr(pt)-1.3* 03:16am blood glucose-121* urean-16 creat-2.0* na-138 k-4.1 cl-101 hco3-30 angap-11 03:16am blood alt-19 ast-28 ld(ldh)-325* alkphos-109 totbili-0.7 03:16am blood albumin-2.9* calcium-8.6 phos-2.3* mg-1.7 03:40am blood type-art po2-68* pco2-54* ph-7.38 caltco2-33* base xs-4 _________________________________________________________ citrobacter koseri | klebsiella pneumoniae | | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- 64 i 64 i piperacillin---------- 16 r piperacillin/tazo----- <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s endotracheal sputum culture _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | cefepime-------------- 2 s <=1 s ceftazidime----------- 2 s 2 s ciprofloxacin---------<=0.25 s 0.5 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s piperacillin---------- <=4 s <=4 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s : joint aspirate: fluid culture (final ): no growth. urine culture , , , , : colonization with alpha streptoccocus and lactobacillus. : mrsa screen: no mrsa isolated. blood cultures on , , , , , : no growth blood cultures: , , : no growth respiratory culture (): no growth, fungal culture: preliminarily no fungus. sputum cultures: , , , , , ,: contamination with oral secretions only. other studies: ekg: sinus rhythm. prolonged p-r interval. right-bundle branch block. non-specific repolarization abnormalities. generalized low voltage. compared to the previous tracing of voltage has decreased and p-r interval has prolonged somewhat. cxr: tracheostomy is present in the midline. orogastric tube courses below the diaphragm, but the tip is not seen. heart is massively enlarged. mediastinum is prominent. central pulmonary vasculature is also prominent consistent with mild congestive failure. there are small bilateral pleural effusions as well as bibasilar atelectasis. there is very little change in the appearance of the chest since the prior study. ct chest/abd/pelvis w/: 1. left lower lobe atelectasis. 2. cardiomegaly. 3. right adrenal nodule not meeting ct criteria for adenoma. mri would be useful to further characterize. 4. anterior wall hernia without bowel strangulation. 5. diverticulosis without evidence of diverticulitis. 6. distended gallbladder, stable from prior exam. 7. no discrete masses, fluid collections, or evidence of abscess formation. echo: left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is markedly dilated with mild global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. there is abnormal septal motion/position. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) 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. the tricuspid valve leaflets fail to fully coapt. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. l wrist x-ray: possible non-displaced fracture of distal radius. ct head: no acute intracranial pathological process. stable chronic changes from prior infarcts. small hyperdensity is seen anterior to the left side of the pons may represent a small meningioma and is unchanged since . brief hospital course: 78 year old female with multiple medical problems including obstructive sleep apnea requiring tracheostomy, diastolic congestive heart failure, atrial fibrillation, chronic clostridium difficile infection presents from ltac with worsening mental status and failure to improve. altered mental status: progressive worsening mental status has been a slow process and likely related to infection. neuro exam was non-focal, but ct was performed that showed no acute process. urine from was positive for citrobacter and klebsiella. she was treated with a course of ciprofloxacin for uti. from patient's mental status was briefly much improved so that she could remember events, and indicate that she was not in pain. patient status waxed and waned over subsequent days with a disturbed sleep/wake cycle suggest underlying delirium liked related to prolonged hospitalization and ventilator dependence. respiratory failure: patient with severe obstructive apnea and obesity hypoventilation. she has been tracheostomy dependent since . respiratory failure was felt to be due to anasarca and volume overload from diastolic failure complicated by known pulmonary hypertension. patient was 100+ lbs above her dry weight; cvvh was initiated after minimal diuresis effect of lasix gtt and zaroxyln. the patient had hypotension on cvvh and various pressors were needed to continue to remove volume. eventually cvvh was stopped after removing around 70kg from the patient. she did well on this cvvh holiday and was able to be trach masked. the patient tired on trach mask and needed to be placed back on ventilator. patient, as below, was transitioned to hd. she will continue to work on ventilator weaning at . acute blood loss anemia and anemia of chronic disease: the patient has had several sites of minor bleeding, including her trach site, vagina, and gi tract. a bronchoscopy was done and no active bleeding was noticed. a ct of the neck was done and it ruled out erosion of the innominate artery. it was also felt that her nutritional status, longstanding chronic illnesses and need for frequent phlebotomy was the reason for her persistently low hematocrit. she recieved at total of 10 units of packed red blood cells during her month long stay in the hospital. we monitored her hematocrit. she will continue to need her hematocrit monitored with a goal hematocrit of greater than 27. leukocytosis/infection: the patient's urinary tract infection was treated with ciprofloxacin. the patient has a history of pseudomonas in her sputum, so she was not started on any antibiotics for her , sputums given the low suspicion for pneumonia at the time her culture was postive. she was treated with po vanc for any recurrence of clostridium difficile throughout her hospital stay. she will continue on po vanc for 14 days after her last dose of any other antibiotics. on when she became hypotensive she was pan cultured and started on vanc, cefepime, cipro, micafungin. when the only positive culture were urine cultures persitently growing yeast ( albicans), her vancomycin, cefepime and ciprofloxacin were discontinued. patient was treated with a 8 day course of micafungin. clostridium difficile infection: patient has had severe malnutrition from longstanding clostridium difficile infection that has perisisted despite po vancomycin. id was consulted for recurrent clostridium difficile. they recommended 14 days of po vanc after her last dose of antibiotics. she was clostridium difficile negative during her micu stay. on discharge she was on day of her po vancomycin course. diastolic heart failure: volume overloaded on admission and was continued on cvvh as needed until patient is stable enough to tolerate hd. hypotension: the patient was initially on levophed and dopamine but had significant ectopy so was switched to neosynephrine to maintain maps >60. when her cvvh was stopped, she was able to weanned off her pressors. however, on when she had hypotension neosynephrine was temporarily restarted. she was quickly weaned off, but had another episode of hypotension on and pressures were restarted. she was weaned off as of am . acute on chronic renal failure: creatinine on admission 1.9. was 1.1-2.2 since , prior had been around 1.3. patient was on cvvh with and without pressors during her hospital course. it was felt that she developed atn during several repeat episodes of hypotension resulting in likely long term need for hemodialysis. however, on the patient became hypothermic, hypotensive and pressors were restarted. patient was treated empirically with antibiotics, but no pathogen was found other than yeast in her urine. she was started on midodrine and treated with micafungin. cvvh was restarted once her pressures stabalized. she had a tunneled line placed on . patient was then transitioned to hd and tolerated it well without a need for pressors. patient will continue with hd at . it is felt that she will not recover enough renal function to be able to stop hemodialysis. h/o breast cancer: was on arimidex, but this was held medication effect with ischemic heart disease. type 2 diabetes mellitus: patient was treated with standing and sliding scale insulin with good blood glucose control. gerd: stable on h2 blocker. hyperlipidemia: stable on simvastatin stage ii sacral decubitus: patient was treated according to wound consult and the ulcer was healed. the patient was full code during this hospitalization medications on admission: acetaminophen 1000 mg po tid nystatin cream 1 appl tp acetylcysteine 20% 3-5 ml neb omeprazole 20 mg po daily albuterol-ipratropium 6 puff ih q6h ondansetron 4 mg iv q8h:prn nausea arimidex *nf* 1 mg oral daily racepinephrine 0.5 ml ih q4h:prn shortness of breath ipratropium bromide neb 1 neb ih q6h:prn shortness of breath vancomycin oral liquid 250 mg po q8h lidocaine 5% patch 1 ptch td qd 12 hours on, 12 off warfarin 2 mg po daily morphine sulfate (oral soln.) 5 mg po q4h:prn pain discharge medications: 1. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: six (6) puff inhalation q6h (every 6 hours). 2. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical every twelve (12) hours: 12 hours on, 12 hours off, to right knee. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 5. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane (2 times a day). disp:*60 ml(s)* refills:*2* 6. epoetin alfa 4,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). disp:*12 * refills:*2* 7. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day): for constipation, please hold for loose stools. disp:*60 * refills:*0* 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for when off vent. disp:*1 * refills:*0* 9. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for off vent. disp:*1 * refills:*0* 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection prn (as needed) as needed for line flush. disp:*1 * refills:*0* 11. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 12. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). disp:*90 * refills:*2* 13. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. 14. insulin glargine 100 unit/ml solution sig: twenty nine (29) units subcutaneous once a day: given at 8am. 15. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous every six (6) hours. 16. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 9 days. 17. normal saline flush 0.9 % syringe sig: five (5) ml injection every four (4) hours as needed for line flush per care protocol. discharge disposition: extended care facility: northeast - discharge diagnosis: primary 1. altered mental status 2. urinary tract infection 3. acute on chronic renal failure, hemodialysis dependent 4. delirium 5. acute blood loss anemia 6. anemia of chronic disease 7. chronic clostridium difficile infection 8. albicans funguria 9. acute on chronic diastolic heart failure 10. type 2 diabetes mellitus 11. stage ii decubitus ulcer secondary gastroesophageal reflux disease hyperlipidemia obstructive sleep apnea atrial flutter discharge condition: fair, with tracheostomy tube, and requiring ventilation. discharge instructions: ms. was admitted to the hospital from rehab because of progressive hypercapnia with declining mental status. this was likely due to an infection and she was treated for a uti. she was found to be volume overloaded and in renal failure, was started on dialysis, initially cvvh to prevent low blood pressures, and is now able to tolerate hemodialysis without dropping her blood pressures. she required intubation with mechanical ventilation. she now only requires pressure support and weaning from ventilator support can be continued at . she also developed progressive renal failure. she had known persistent c-diff infection, for which she was treated with oral vancomycin. because of this infection, she requires supplemental nutrition and is now receiving elemental tube feeds via a doboff tube. she was anemic due to bleeding and her malnutrition, which has now improved with blood transfusions, iron and cessation of bleeding. continued hematocrit monitoring will be needed, with goal above 27. the following changes were made to her medications: new: vancomycin po day atorvastatin 80 mg daily to help protect your heart chlorhexidine mouthwash to help prevent pneumonia epogen to help support your red blood cells docusate sodium to help prevent and treat constipation your insulin was adjusted to help control your blood sugars. your omeprazole was changed to famotidine. you were treated with oral vancomycin due to your history of chronic clostridium difficile infection. you were started on midodrine to help with your blood pressure. you were started on subcutaneous heparin to help with prevent blood clots. discontinued: your omeprazole was changed to famotidine. your warfarin was stopped due to recurrent episodes of bleeding. your should discuss with your primary care doctor and benefits of restarting this medication. your arimidex was stopped due to the cardiovascular side effects. your acetylcysteine was stopped as you are on other medications for your breathing. your zofran was stopped and you have not endorsed any nausea. your morphine was stopped and you have had not complaints of pain. followup instructions: please follow up with pcp at at . provider: , m.d. phone: date/time: 2:40 provider: phone: date/time: 8:00 provider: , : date/time: 9:20 md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis arterial catheterization bronchoscopy through artificial stoma bronchoscopy through artificial stoma bronchoscopy through artificial stoma insertion of totally implantable vascular access device [vad] insertion of totally implantable vascular access device [vad] diagnoses: end stage renal disease obstructive sleep apnea (adult)(pediatric) esophageal reflux mitral valve disorders urinary tract infection, site not specified congestive heart failure, unspecified acute posthemorrhagic anemia acute kidney failure, unspecified unspecified septicemia severe sepsis acute on chronic diastolic heart failure other chronic pulmonary heart diseases atrial flutter hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute and chronic respiratory failure ostium secundum type atrial septal defect long-term (current) use of insulin blood in stool septic shock intestinal infection due to clostridium difficile morbid obesity pressure ulcer, lower back iron deficiency anemia, unspecified other disorders of plasma protein metabolism ventilator associated pneumonia delirium due to conditions classified elsewhere diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled pressure ulcer, stage ii nutritional marasmus other tracheostomy complications edema surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation effusion of joint, forearm 

Answer: The patient is high likely exposed to