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: lorazepam / morphine / penicillins / zosyn attending: chief complaint: fever and leukocytosis major surgical or invasive procedure: endotracheal intubation history of present illness: 74 yr old woman with hx of afib/flutter, tachy-brady syndrome s/p in , chf (ef 20%), copd s/p trach in who was recently hospitalized in from with pseudomonas pneumonia and was discharged on aztreonam to rehab after developing rash with zosyn. the patient is unable to provide history. per family, she was doing well the day after the discharge, but about 48 hours prior to admission she became agitated, developed low grade fevers and had increased wbc from 20 to 60. she was noted to have increased rash that spread to her arms and legs. per family, the patient also developed diarrhea a few days prior to admission. . on presentation to the ed, the patient's vital signs temp 101.6, bp 84/49, hr 96, rr 19, o2 sat 98% on vent. wbc 60.3 and lactate initially 5.8. her cxr showed no chf or infiltrate. in the ed must protocol initiated. left femoral line was placed and she received vancomycin 1 gm iv once, flagyl 500 mg iv, protonix 40 mg iv, tylenol 650 mg once, hurricane spray, urojet, anzemet, haldol 0.5 mg iv x1. levophed started. patient received total of 3l ns. sbp 80's -> 154. lactate came down to 3.8. . on arrival to the icu, patient afebrile, sbp 100/51, she was on levophed at 0.03 initially that was quickly weaned off. the patient denies any complaints. no cp, no sob, no pain. she does endorse itching due to rash. past medical history: * icu stay with rul pseudomonas pna - treated with aztreonam * recent hx of enterococcal uti and sinusitis, treated with augmentin * afib/aflutter * tachy-brady syndrome s/p dual chamber in * chf (echo : lv ef < 20%. global hypokinesis. 3+ mr, 2+ tr * htn * copd/asthma s/p trach in * s/p bowel perforation in * remote hx of seizure * h/o lower gi bleed in social history: sh: lives at ; daughter is hcp; former , no etoh or drug use. family history: noncontributory; no known hx of heart/lung dz. physical exam: vs: t 98.2 hr 97 bp 100/51 rr 19 o2 sat 97% on vent vent: cmv 500 x 12 (5) peep 5 fio2 of 0.5 gen: awake and alert, appears in mild distress; gestures to simple questions appropriately heent: trach collar in place with some purulent drainage; oropharynx clear, mm slightly dry; no erythema; no lesions cv: regular, distant; nl s1, s2; no murmurs heard chest: crackles at bases; no wheezing abd: +bs, obese, soft, nontender, nondistended; several ecchymoses over abdomen ext: no edema; left foot cooler to touch that right and rn unable to dp or tp pulse neuro: cn 2-12 intact, moves all extremities skin: diffuse well demarkated erythematous areas pertinent results: admission labs: . 03:15pm pt-13.9* ptt-25.8 inr(pt)-1.3 03:15pm plt smr-high plt count-437# 03:15pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 03:15pm neuts-70 bands-25* lymphs-1* monos-2 eos-0 basos-0 atyps-1* metas-1* myelos-0 03:15pm wbc-60.3*# rbc-4.01*# hgb-12.4# hct-39.2# mcv-98 mch-30.9 mchc-31.6 rdw-15.9* 03:15pm calcium-9.3 phosphate-2.8# magnesium-1.6 03:15pm ck-mb-notdone 03:15pm ctropnt-0.29* 03:15pm lipase-16 03:15pm alt(sgpt)-22 ast(sgot)-33 ck(cpk)-69 alk phos-304* amylase-29 tot bili-0.3 03:15pm glucose-153* urea n-44* creat-1.7* sodium-142 potassium-4.2 chloride-99 total co2-29 anion gap-18 03:18pm lactate-5.8* 05:08pm hgb-9.8* calchct-29 o2 sat-97 05:08pm lactate-3.9* 06:05pm lactate-3.8* 07:05pm lactate-3.4* 08:01pm hgb-11.2* calchct-34 o2 sat-65 08:01pm type- temp-36.1 10:00pm pt-14.0* ptt-26.1 inr(pt)-1.3 10:00pm plt smr-normal plt count-373 10:00pm hypochrom-1+ anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 10:00pm neuts-64 bands-27* lymphs-2* monos-5 eos-0 basos-0 atyps-0 metas-1* myelos-1* 10:00pm wbc-56.4* rbc-3.60* hgb-11.4* hct-34.2* mcv-95 mch-31.6 mchc-33.2 rdw-16.0* 10:00pm calcium-8.3* phosphate-2.8 magnesium-1.3* 10:00pm ck-mb-notdone ctropnt-0.28* 10:00pm lipase-15 10:00pm alt(sgpt)-38 ast(sgot)-52* ld(ldh)-333* ck(cpk)-50 amylase-28 10:00pm glucose-96 sodium-141 potassium-3.8 chloride-103 total co2-25 anion gap-17 10:50pm cortisol-40.7* 11:40pm digoxin-1.3 11:40pm cortisol-42.6* pertinent labs/studies: . cxr : comparison with . the tracheostomy tube is unchanged. an ng tube extends below the level of the hemidiaphragm. the pacer electrodes are unchanged in position. the patient is rotated, but the cardiac and mediastinal contours appear stable. there are no definite consolidations. no definite pleural effusions, pulmonary vascular congestion, or pneumothorax. . chest ct : 1. no evidence of central upper extremity vascular stenosis. 2. multifocal air space opacities within the right and left upper lobes, consistent with pneumonia. mediastinal lymphadenopathy is likely reactive. 3. six millimeter nodular density within the right upper lobe. 3-month followup ct of the chest is recommended. 4. enlarged central pulmonary arteries, consistent with underlying pulmonary arterial hypertension. . abd ct : 1. interval development of ill-defined areas of low attenuation in segment vii and vi of the liver. these could represent developing abscesses. due to the peripheral location of these areas, ischemic etiology is also a consideration. 2. vague areas of wedge shaped low attenuation in both kidneys. these could be secondary to infectious or ischemic etiology. clinical correlation is recommended. 3. persistent bilateral pleural effusions. . ruq us (): 1. no ultrasound correlate for the renal or hepatic abnormality is detected on previous ct is seen. 2. gallbladder polyp. . tte () technically difficult study: 1.the left atrium is normal in size. the left atrium is markedly dilated. 2. while difficult to assess it appears that the left ventricular wall thicknesses are severely thickened. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. 5. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. no mitral regurgitation is seen. 6.there is moderate pulmonary artery systolic hypertension. 7.there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. impression: limited study but no clear evidence of endocarditis. compared to the previous study of , there is a maked improvement in biventricular function. compared to the previous study, the lvh is much greater, which is probably a result of previous underestimation of the lv septum and posterior wall. . cxr () dramatic interval increase in size of a right pleural effusion. given interval subclavian central venous catheter placement on that side, bleeding cannot be excluded. . us ( eval) ; 2 x 1 cm turbid fluid collection superior aspect of box. hematoma vs infection. . cxr () right hemothorax or pleural effusion has not recurred. lungs are hyperinflated. the region of left apical peribronchial infiltration could represent either deposition of edema in the region of scarring or new early infection. followup advised. pulmonary arteries are chronically enlarged, indicating pulmonary hypertension while heart shadow is top normal size. there is no pneumothorax. right subclavian line and a tracheostomy tube and transvenous right atrial and right ventricular pacer leads follow their expected courses. . cxr : comparison with . the tracheostomy tube is unchanged. an ng tube extends below the level of the hemidiaphragm. the pacer electrodes are unchanged in position. the patient is rotated, but the cardiac and mediastinal contours appear stable. there are no definite consolidations. no definite pleural effusions, pulmonary vascular congestion, or pneumothorax. . chest ct : 1. no evidence of central upper extremity vascular stenosis. 2. multifocal air space opacities within the right and left upper lobes, consistent with pneumonia. mediastinal lymphadenopathy is likely reactive. 3. six millimeter nodular density within the right upper lobe. 3-month followup ct of the chest is recommended. 4. enlarged central pulmonary arteries, consistent with underlying pulmonary arterial hypertension. . abd ct : 1. interval development of ill-defined areas of low attenuation in segment vii and vi of the liver. these could represent developing abscesses. due to the peripheral location of these areas, ischemic etiology is also a consideration. 2. vague areas of wedge shaped low attenuation in both kidneys. these could be secondary to infectious or ischemic etiology. clinical correlation is recommended. 3. persistent bilateral pleural effusions. . ruq us (): 1. no ultrasound correlate for the renal or hepatic abnormality is detected on previous ct is seen. 2. gallbladder polyp. . tte ()technically difficult study.: 1.the left atrium is normal in size. the left atrium is markedly dilated. 2. while difficult to assess it appears that the left ventricular wall thicknesses are severely thickened. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. 5. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. no mitral regurgitation is seen. 6.there is moderate pulmonary artery systolic hypertension. 7.there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. impression: limited study but no clear evidence of endocarditis. compared to the previous study of , there is a maked improvement in biventricular function. compared to the previous study., the lvh is much greater, which is probably a result of previous underestimation of the lv septum and posterior wall. . cxr () dramatic interval increase in size of a right pleural effusion. given interval subclavian central venous catheter placement on that side, bleeding cannot be excluded. . us ( eval) 2 x 1 cm turbid fluid collection superior aspect of box. hematoma vs infection. . cxr () right hemothorax or pleural effusion has not recurred. lungs are hyperinflated. the region of left apical peribronchial infiltration could represent either deposition of edema in the region of scarring or new early infection. followup advised. pulmonary arteries are chronically enlarged, indicating pulmonary hypertension while heart shadow is top normal size. there is no pneumothorax. right subclavian line and a tracheostomy tube and transvenous right atrial and right ventricular pacer leads follow their expected courses. . cxr () bilateral pleural effusion, moderate to large on the left and moderate on the right has increased since , particularly on the left. left lung base is airless. heart is mildly enlarged, increased since . transvenous right atrial and ventricular pacer leads project over their expected courses. right subclavian line tip projects over the brachiocephalic vein. et tube in standard placement. . cxr () 1. findings consistent with worsening congestive heart failure and pulmonary edema. 2. interval apparent significant increase in size of right pleural effusion. while this may be accounted for by worsening congestive heart failure and patient positioning, a hemothorax should be considered if there has been interval attempted intervention on this side. . ekg: sinus rate 95, nl axis, nl intervals, st depressions in ii, iii, avf unchanged from prior ekg, st depressions in v3-v6. brief hospital course: a/p (): 74 yr old female with hx of afib/flutter, tachy-brady syndrome s/p ppm, chf, copd, h/o bowel perforation s/p trach presents to the micu with fever, leukocytosis and hypotension. . 1. sirs/sepsis: upon presentation, the pt's fit the criteria for sirs/sepsis, and the most likely sources of infection were bowel (in particular cdiff, given diarrhea and high degree leukocytosis), urinary (h/o uti), lung (recent h/o pseudomonas ppneumonia), skin (pt. has picc line), and liver abscesses (given findings on abd ct). the pt. was started on empiric vancomycin, flagyl, and aztreonam, and a levophed gtt for blood pressure support. the patient was also treated with hydrocortisone and fludricortisone after -stim test was done. stool was found to be negative for cdiff x3, and was negative for cdiff toxin b. urine culture grew , vancomycin was switched to linezolid. sputum culture grew pseudomonas, so aztreonam was continued. a fluid collection in the pt's pocket was evaluated by ultrasound, and then drained, and did not grow bacteria. with no source of an anaerobic infection, flagyl was d/c'd after 3 days. blood and fungal cultures remained negative. the pt. had an a-line placed, which revealed pressures approximately 20-30 mmhg higher than non-invasive blood pressures, and greater than her goal map>60. her levophed was d/c'd, and the patient remained off pressors for the remainder of the hospitalization. her wbc count gradually decreased during the hospitalization. her lactate levels and mixed venous o2 were trended. . as of , pt's condition had been worsening over the past 24 hours, and pt. was already dnr but decision was made with family that bp would not be supported with pressors. the pt. was unresponsive to to any stimuli, and bp continued to trend down overnight. the pt's k was found to be 10 and lactate was 7.3. the pt. was hypoglycemic despite d50 and a d10 gtt. sequential venous blood gases were 7.04 to 6.91. discussion with the family, who was present throughout the night refocused the point of care on pt. comfort, rather than treating abnormal lab values. the family was agreeable to this appraoch and there were no additional interventions. at 4:00a, telemetry revealed a switch from atrial pacing to av pacing and a bp of 34/22. shortly thereafter no pulse could be auscultated. the pt. expired at 4:20a, with the son and husband at the bedside at the time of death. a post-mortem examination was offered and denied by the pt's family. . 2. recent pseudomonas pneumonia. with a positive sputum culture, the pt. was continued on aztreonam. . 3. chf: the pt. underwent an echo after admission which revealed no evidence of endocarditis and an lvef of >75%. pt seemed to be 3rd spacing iv fluids, and during the time the pt. was on levophed, her urine output decreased to <5cc/hr and her cr rose to a peak of 2.5. the cvp was fairly consistent in the range. metoprolol, lasix, and ace-i were held initially, and metoprolol was restarted prior to discharge for afib rate control. is/os and daily weights were monitored. the pt. was found to have large effusions in lung bases, these were monitored as the pt. was treated with lasix, but their resolution was probably limited by poor urine output/diuresis/atalectasis. . 4. rhythm. patient with tachy-brady syndrome s/p pcm. ep recently interrogated pacer and found that her episodes of tachycardia are due to her native rhythm breaking through. pt. reverted to afib during the admission, and metoprolol and digoxin were restarted, which kept the pt. in normal sinus rhythm. . 5. elevated troponin on admission, likely related to sepsis/arf. troponin, and other ces trended down during hospitalization. pt was consistenly chest pain free, but had some st depressions on ecg. her daily asa was continued. bb was held initially, but restarted. . 6. copd: pt on chronic vent support and was being weaned at rehab. pt's baseline hco3 appears to be 37-40 due to chronic hypercapnea. the pt's initial vent settings were ac fio2 0.50 vt 500 x . pt. was switched to pressure support with settings cpap+ps 10/5 fio2 0.40 vt~600 x . the patient was never able to tolerate cpap, and her work of breathing increased. we were ultimately unable to completely wean pressure support. the pt. received both standing and prn albuterol and atrovent nebs throughout the hospitalization. . 7. arf. baseline cr=0.8. pt's cr rose steadily to a peak of 2.5. likely due to a combination of factors including effects of sepsis, possible renal ischemia due to pressors/hypotension. arf likely pre-renal in setting of diarrhea but given ct finding of wedge shaped areas in kidney ischemic event is also possible. the patient was treated for uti with linezolid, and urine output steadily improved once the pt. was off pressors. no urine eosinophils were found. aggresive diuresis was attempted, which initially yielded improved urine output and decreased cr, but eventually led to a rise in creatinine and anuria. . 8. pvd: the patient was noted to have a cool left foot on exam. this was likely due to her history of peripheral vascular disease. she always maintained both dp and pt pulses in the left foot. a surgical consult was considered but deferred as the vessels would be unlikely to be intervenable given other acute issues. . 9. fen: pt. was initially npo, but eventually was able to tolerate tube feeds at a goal of 45cc/hr. the patient was followed by nutrition. given phos-lo for hyperphosphatemia. . 10. pain: tylenol and oxycodone liquid. . 11. rash: pt. developed a diffuse erythematous papular rash which was pruritic. pt. was seen by dermatology, who recommended topical steroids, which helped the rash to resolve. likely drug reaction (zosyn), has progressed from erythematous papules to confluent erythroderma with ?skin sloughing with dressing changes. topical steroid creams. a punch biopsy of the skin on the l thigh was performed; results of this biopsy are pending at the time of this summary. . 12. ppx: sq heparin, ppi. . 13. psych: pt. had been started on seroquel recently, but this was d/c'd because daughter (hcp) was uncomfortable with pt. receiving this medication. . 14. code: pt. was initially full code, but after a family meeting with pt. present, decision was made to change code status to dnr. medications on admission: 1. bisacodyl 10 mg po qd prn. 2. docusate sodium 150 mg/15 ml po bid. 3. digoxin 125 mcg po daily. 4. acetaminophen prn. 5. furosemide ? 80 mg po at bedtime and 40 mg po qam. 6. metoprolol tartrate 50 mg po bid. 7. fluticasone 110 mcg 2 puff 8. quetiapine 25 mg po qhs. 9. quetiapine 12.5 mg po bid prn. 10. aspirin 81 mg po daily. 11. heparin 5,000 sq tid. 12. phenol-phenolate sodium 1.4 % q4h as needed. 13. lansoprazole 30 mg susp po bid. 14. albuterol-ipratropium 103-18 mcg 1-2 puffs inhalation q6h prn. 15. lisinopril 20 mg po daily 16. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours). 17. diphenhydramine hcl 12.5 mg/5 ml elixir po q6h prn. 18. spironolactone 25 mg po daily. 19. aztreonam 1g q8h for 11 days. discharge medications: not applicable. discharge disposition: expired discharge diagnosis: primary: copd secondary: cad, atrial fibrillation, htn, chf discharge condition: expired. discharge instructions: not applicable. followup instructions: not applicable. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances arterial catheterization closed [endoscopic] biopsy of bronchus transfusion of packed cells closed biopsy of skin and subcutaneous tissue injection or infusion of oxazolidinone class of antibiotics diagnoses: subendocardial infarction, initial episode of care urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia iron deficiency anemia secondary to blood loss (chronic) severe sepsis chronic airway obstruction, not elsewhere classified atrial fibrillation acute respiratory failure pneumonia due to pseudomonas disorders of phosphorus metabolism septic shock abscess of liver cardiac pacemaker in situ dermatitis due to drugs and medicines taken internally diarrhea streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] encounter for palliative care sinoatrial node dysfunction tracheostomy status 

Answer: The patient is high likely exposed to