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: latex / benadryl / penicillins / clindamycin / shellfish derived / ibuprofen / codeine / bactrim / aspirin attending: chief complaint: shortness of breath and fevers major surgical or invasive procedure: picc line insertion history of present illness: 66 yo f with pmh of morbid obesity, paf, dm2, copd on 2l home oxygen, cad and recent diagnosis of pe who presents from osh with sob and fevers. she was taken from rehab to hospital with sob and fever to 100. she was recently at in the beginning of with sob. it was thought that she likely had pe. given her shellfish allergy, she had a vq scan rather than a cta. this returned indeterminant and the decision was made to treat her with coumadin for presumed pe. she also had a cellulitis on her pannus and was sent to rehab on vancomycin and ceftazidine which ended on . . in the ed, her initial vitals were t 101.8, hr 94, bp 166/30, rr 28, o2sat 95% 3l nc. she was noted to have a subtherapeutic of 1.8 and she was started on a heparin gtt. she also complained to ruq pain and had an ultrasound which was negative. a cxr was also negative. a u/a was positive and it was thought she had a uti from a foley catheter. she was admitted to cc7 for further work up. on admission there, she was in no acute distress. she noted her sob was improved but was still having fevers. she was given vancomycin and ceftriaxone for uti antibiotics and the plan was to likely send her home in the am. . a trigger was called shortly after admission for hypoxia and tachypnea. she was found to have blue lips and sob. she also felt chest pain that was across her entire chest wall and around to her back. she had an ekg which was unchanged, given nitroglycerin which did not change her pain. she was also given nebulizers for wheezing, and given lasix but did not put out much to it. another cxr was performed which was largely unchanged. she had an abg which was 7.26/65/339 on nrb. she was changed to a 35% face mask. she was transferred to the icu for further care. . currently, she feels her breathing is slightly improved but still not at baseline. she still has some chest pain as well. +nausea. no vomiting. no abdominal pain currently. +fevers. no chills. can not assess dysuria given foley in place. no diarrhea. past medical history: pmhx: per patient and osh records: -spina bifida repair at 10days old -atrial fibrillation -dm2 -copd on home oxygen of 2l nc -asthma -cad -h/o pulmonary embolisms -gerd -depression -angiodysplasia -anxiety -h/o cellulitis -multiple icu admissions for sepsis, cellulitis, anaphylaxis -skin graft for ulcers -benign left breast mass -osa uses bipap 12/8 with 2l oxygen social history: smoked in the past but quit 20 years ago. currently wheelchair bound and oxygen depended on 2l nc from copd. has a sister who is next of . currently lives at nursing home on the . family history: noncontributory. physical exam: vs - t 102, bp 134/84, rr 35, hr 86 o2sat 94% on 3l general: morbidly obese, nad, mildly tachypnic. using some excessory muscles when breathing. heent: perrl, eomi, anicteric sclera. clear conjunctiva. dry mucous membranes. cvs: irregular,irregular, no m/r/g pulm: bibasilar scattered rales, no wheezing or rhonchi abd: obese. +bs, soft, moderate tenderness at epigastrum, no rebound or guarding, some tenderness to percussion over ruq. no lesions or ulcerations under abdominal panus. ext: 2+ pitting edema bilaterally, venous stasis changes in lower calfs at medial margins. skin breakdown in folds of posterior calf bilaterally. small sacrul ulcer. mild erythema of l posterior thigh. pertinent results: admission labs: wbc-7.3 rbc-3.67* hgb-10.1* hct-31.1* mcv-85 mch-27.6 mchc-32.5 rdw-15.1 plt ct-140* neuts-89.4* lymphs-7.4* monos-2.1 eos-0.6 baso-0.4 pt-19.7* ptt-27.3 (pt)-1.8* glucose-98 urean-18 creat-0.8 na-138 k-4.4 cl-97 hco3-30 alt-13 ast-22 ck(cpk)-17* alkphos-82 amylase-45 totbili-0.3 calcium-8.7 phos-2.4* mg-1.7 ctropnt-<0.01 tsh-4.5* blood type-art po2-339* pco2-65* ph-7.26* caltco2-31* base xs-0 glucose-94 lactate-2.4* na-140 k-4.4 freeca-0.45* urine color-yellow appear-clear sp -1.017 urine blood-mod nitrite-pos protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-mod urine rbc-0-2 wbc->50 bacteri-many yeast-none epi-0 2:20 pm urine site: catheter **final report ** urine culture (final ): enterobacter cloacae. >100,000 organisms/ml.. 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. enterobacter cloacae. 10,000-100,000 organisms/ml.. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | enterobacter cloacae | | cefepime-------------- 2 s 8 s ceftazidime----------- =>64 r =>64 r ceftriaxone----------- =>64 r =>64 r 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---------- =>128 r =>128 r tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r 11:05 am blood culture from picc line # 1. **final report ** blood culture, routine (final ): enterobacter cloacae. final sensitivities. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | cefepime-------------- 4 s ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin---------- =>128 r tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r aerobic bottle gram stain (final ): reported by phone to @ 1:39a . gram negative rods. anaerobic bottle gram stain (final ): gram negative rods. studies: ekg: sinus rhythm with premature ventricular contractions. prolonged a-v conduction. left axis deviation. right bundle-branch block with left anterior fascicular block. lateral st-t wave changes. compared to the previous tracing of the premature ventricular contractions are new. ruq ultrasound: impression: 1. normal-appearing gallbladder without gallstones or signs suggestive of cholecystitis. 2. echogenic liver consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. cxr - right picc line has been replaced or advanced to the low svc. lung volumes are low, but aside from mild linear scarring or atelectasis at the right base, clear. moderate cardiomegaly is stable. mediastinal vascular engorgement is persistent, either an indication of elevated central venous pressure or anatomic variant. bilateral le veins: impression: no evidence of deep vein thrombosis in either leg. cxr - impression: probable right lower lobe pneumonia. ct abdomen & pelvis - impression: 1. nonobstructed subcentimeter right intrarenal calculus. no evidence for hydronephrosis. no ureteral calculus. 2. no evidence for acute bowel pathology. 3. severe degenerative changes of the spine. brief hospital course: 66 yo f with pmh of morbid obesity, paf, dm2, copd on 2l home oxygen, cad and recent diagnosis of pe who presents from osh with sob and fevers. . # sob: most likely due to aspiration given coughing with food observed on morning rounds. pna is unlikely, but was started on ceftriaxone and vancomycin in the setting of fevers and gnr bacteremia. lenis were negative for dvt. steroids, vancomycin and ceftriaxone were stopped on . the patient was placed on bipap at night per her home regimen. her shortness of breath was likely due to a combination of copd and aspiration of secretions. she was evaluated by speech and swallow who determined that she was not aspirating food or liquids but did have thick secretions which she was aspirating. she can eat a regular, heart healthy diet and should have appropriate copd treatment as per her home regimen. . # gnr bacteremia: likely from a urine source. blood is growing enterobacter that is ceftriaxone/cephalosporin resistant. on she was switched to ciprofloxacin when sensitivities became available. she should complete a 14 day course of cipro for her bacteremia. this will end on . she also had an abdominal ct that was negative for perinephric abscess given bacteremia from presumed pyelonephritis. . # hypocalcemia: on presentation the patient had acute hypocalcemia on venous blood gas. she was repleted with 4g calcium gluconate and her calcium has remained stable since. ionized calciums were trended. . # copd: the patient was initially treated for a copd flare, but this was stopped as it was felt that her sob was more likely related to aspiration. she was continued on her home regimen of advair and singular. . # pe: unclear if the patient actually had a pe on prior admission given that her area of mismatch on v/q scan was in the same location as a pleural effusion. she was started on a heparin gtt on admission and it was stopped on when she was therapeutic on warfarin. she became supratherapeutic on warfarin due to her antibiotics and it was stopped on . please see below for further instructions regarding anticoagulation. . # afib: the patient was continued on metoprolol. she had some episodes of rvr on and her metoprolol dose was increased to 75 mg po tid. her anticoagulation was managed as discussed below with heparin and coumadin. . # anticoagulation: the patient was subtherapeutic on warfarin on admission ( 1.8). she was started on heparin gtt and warfarin was continued. heparin was stopped when became therapeutic. the patient was started on ciprofloxacin for bacteremia from a urine source on . as fluoroquinolone antibiotics interact with warfarin and prolong the ( 3.5 on , the morning of discharge), her warfarin dose should be decreased from 3 mg to 2mg daily and her more closely monitored on discharge so that her warfarin dose can be adjusted accordingly. when she finishes her course of ciprofloxacin her warfarin dose will need to be increased accordingly so that she does not become subtherapeutic. . # cad: not on asa given allergy. continue bb as above. not on statin, unclear why. . # dm2: the patient was placed on an insulin sliding scale and metformin was held for imaging. . # depression: sertraline was continued per home regimen. . # chronic pain: gabapentin and tramadol continued per home regimen. . # fen: regular diet, not aspirating per speech and swallow evaluation. . # ppx: warfarin for anticoagulation. h2 blocker per home regimen for gi ppx. bowel regimen. . # access: picc line placed and then removed given bacteremia. . # code: pt was dnr/dni but reversed her code status to full code during her trigger on the floor. her code status should be reassessed. medications on admission: per last d/c summary: -sertraline 50 mg tablet sig: one (1) tablet po daily -montelukast 10 mg tablet sig: one (1) tablet po daily -levothyroxine 237 mcg daily -gabapentin 400 mg capsule sig: one (1) capsule po tid -metoprolol tartrate 50 mg tablet sig: one (1) tablet po every eight (8) hours. -tramadol 50 mg tablet sig: one (1) tablet po bid (2 times a day): hold for oversedation or rr<10 . -insulin lispro 100 unit/ml solution sig: as dir subcutaneous asdir (as directed): continue prior ssi coverage: start at 6 units for 201-250, 8 units for 251-300, 10 units for 301 to 350 range and 12 units for 351-400 range fsg levels at mealtime and reduce each level by 2 for qhs scale . -ranitidine hcl 150 mg tablet sig: one (1) tablet po hs (at bedtime). -os-cal 500 + d 500 (1,250)-400 mg-unit tablet, chewable sig: one (1) tablet, chewable po twice a day. -metformin 1,000 mg tablet sig: one (1) tablet po twice a day. -fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). -senna 8.6 mg tablet sig: one (1) tablet po bid -bisacodyl 5 mg tablet sig: one (1) tablet po once a day as needed for constipation. -ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h as needed for wheeze. -azo cranberry mg-mg-million tablet sig: one (1) tablet po twice a day. -miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) for 2 weeks. -hydroxyzine hcl 25 mg tablet sig: one (1) tablet po three times a day as needed. -warfarin 3 mg tablet sig: one (1) tablet po once a day: discharge medications: 1. gabapentin 400 mg capsule sig: one (1) capsule po tid (3 times a day). 2. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 3. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 4. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 5. levothyroxine 75 mcg tablet sig: 0.5 tablet po daily (daily). 6. tramadol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. bisacodyl 5 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 9. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. 10. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 11. ciprofloxacin 250 mg tablet sig: three (3) tablet po q12h (every 12 hours) for 14 days. start date = , last day = 12. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po tid (3 times a day). 13. ranitidine hcl 150 mg tablet sig: one (1) tablet po at bedtime. 14. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 15. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) inhalation every six (6) hours as needed for wheezing. 16. miconazole nitrate powder sig: one (1) application miscellaneous twice a day. 17. outpatient lab work please check daily. resume coumadin dosing when between 2 and 3. discharge disposition: extended care facility: skilled nursing nad rehab discharge diagnosis: primary diagnoses: 1. urinary tract infection 2. bacteremia due to enterobacter 3. aspiration of secretions 4. atrial fibrillation with rapid ventricular rate 5. chronic obstructive pulmonary disease secondary diagnoses: 1. type 2 diabetes 2. asthma 3. gastroesophageal reflux disease 4. history of pulmonary embolisms 5. obstructive sleep apnea 6. depression discharge condition: stable, at baseline o2 requirements, afebrile. discharge instructions: you were admitted to the hospital for shortness of breath and fevers. you were found to have bacteria in your blood, likely because you had a urinary tract infection which spread to the blood. you are being treated with the antibiotic ciprofloxacin and will need to complete a total of 14 days of treatment with this antibiotic. because this antibiotic interacts with warfarin, your will need to be monitored and your warfarin dose adjusted accordingly. you were also noted to have difficulties breathing while you are eating. you had a special swallow study and you are not aspirating food at this time, however, you are aspirating some of your secretions and this may be contributing to your shortness of breath and chest discomfort. please eat all meals sitting upright and continue to wear your bipap machine at night. please attend to oral hygiene to reduce the bacteria in your mouth. the following changes were made in your medications. please take ciprofloxacin 750 mg q12h through . your metoprolol dose was increased to 75 mg tid. your warfarin dose was decreased to 2 mg while you are on ciprofloxacin but your is still high so your coumadin was held. once your is between 2 and 3, you should re-start coumadin at 2mg, and it should be increased back to 3 mg when you are finished with the ciprofloxacin. you should have your checked every day to determine the proper dosing of coumadin. please call your physician or return to the hospital if you develop fevers > 100.4, chills, night sweats, worsening shortness of breath, productive cough or other symptoms that concern you. followup instructions: please follow-up with your primary care provider within the next 2 weeks. procedure: venous catheterization, not elsewhere classified injection of antibiotic diagnoses: hypocalcemia obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery esophageal reflux urinary tract infection, site not specified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis atrial fibrillation personal history of tobacco use dysthymic disorder long-term (current) use of insulin pressure ulcer, other site morbid obesity long-term (current) use of anticoagulants pressure ulcer, lower back personal history of venous thrombosis and embolism infection and inflammatory reaction due to other vascular device, implant, and graft chronic obstructive asthma, unspecified urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure accidents occurring in residential institution allergy to latex other respiratory abnormalities pressure ulcer, stage ii septicemia due to gram-negative organism, unspecified pressure ulcer, unspecified stage foreign body in respiratory tree, unspecified personal history of allergy to penicillin allergy to seafood 

Answer: The patient is high likely exposed to