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: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: intubation lumbar puncture history of present illness: 67f with end stage multiple sclerosis c/b torticollis who presents to ed from long-term care facility with ams. patient with chronic indwelling foley, and she finished a course of cipro on for a uti. she became increasing altered in the days prior to admission and became unresponsive in the ed. she was admitted to the icu with bp of 86/40 and was intubated for airway protection. she was fluid responsive, and never on pressors. initially she put on vanc/cefepime/cipro for sepsis of unknown source. urine cx grew vanc-sensitive enterococcus, and abx were narrowed to vanc alone. due to persistent altered state, eeg was ordered which showed concern for non-convulsive status epilepticus. she was by neuro and started on keppra with resolution of seizure activity. lp, although difficult, was negative for high op, meningitis, and hsv. she remained intubated until . prior to extubation, tan secretions were noted and she was placed on vap protocol with vanco, tobra (given no cipro for seizures), zosyn. minibal and sputum cx are pending. . currently, patient denies difficulty breathing or cough. she is hungry, asking for doritos, and denies abdominal pain or nausea. she has no headache. past medical history: - multiple sclerosis diagnosed at age 30, wheel chair bound since - torticollis - scoliosis s/ rod placement - constipation - chronic pain - allergic rhinitis - depression - peripheral vascular disease - urinary incontinence - neurogenic bladder with chronic foley catheter - htn - osteoporosis - obstructive hydrocephalus - insomnia social history: has been living in a nursing facility for about the past 2 years. is divorced and has one son who is her only support outside the facility. no tobacco, alcohol, or drug use per son. family history: parents lived till mid 80s w/o major medical ailments. father died of heart attack. grandmother developed dementia at last year of her life. physical exam: fex on micu admission vitals: t: 101, bp: 130s-170s/40s-90s, p: 120s-130s, r: 15 o2: 100% on ac with tv=400, peep=5, fios=50% general: intubated/sedated, responds to painful stimuli heent: sclera anicteric, dry mm, et tube in place, perrl neck: muscle contractures with rightward head deviation from torticollis cv: tachcardic, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley in place ext: bilateral upper extremities appear mottled and cool to the touch with good pulses. lower extremities are warm, well perfused, 2+ pulses, no clubbing or edema neuro: intubated/sedated, responds to painful stimuli, opens eyes spontaneously, marked muscular contractures, rightward head deviation from torticollis fex on discharge vs - 98.8 98.3 159/77 96 20 97%ra general: awake, alert, oriented and appropriate heent: sclera anicteric, mmm neck: muscle contractures with rightward head deviation from torticollis cv: rrr, no murmurs, rubs, gallops lungs: appears comfortable on ra. limited posterior ausculatation clear. abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley in place ext: no cce, no joint swelling or pain, rle with anterior bruising, no increased swelling or pain. neuro: awake, alert, and oriented. good attention and follows commands. marked muscular contractures, rightward head deviation from torticollis. strength unchanged pertinent results: pertinent microbiology: 12:04 pm mini-bal **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): 10,000-100,000 organisms/ml. commensal respiratory flora. time taken not noted log-in date/time: 11:54 am blood culture **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. of two colonial morphologies. isolated from only one set in the previous five days. sensitivities performed on request.. enterococcus faecalis. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. daptomycin = 2.0 mcg/ml sensitive sensitivity testing performed by etest. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s penicillin g---------- 2 s vancomycin------------ 1 s anaerobic bottle gram stain (final ): reported to and read back by @ 0503 on - . gram positive cocci. pairs and short chain. aerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. reported to and read back by dr. 12:18pm. time taken not noted log-in date/time: 11:11 am urine **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ 2 s . . pertinent studies: radiology chest port. line placem rotated positioning. previously seen left ij catheter has been removed. left subclavian picc line is present. the tip may be partially obscured by the spinal hardware. however, i suspect it is unchanged in position and likely lies at the svc/ra junction. no pneumothorax is detected. again seen is obscuration of the left diaphragm and increased retrocardiac density. there is more pronounced patchy opacity at the right base. suspect mild pulmonary vascular plethora. radiology chest (portable ap) interval extubation. stable bilateral pleural effusions, large on the left and small on the right. possible minimal pulmonary edema. neurophysiology eeg this is an abnormal continuous icu monitoring study because of frequent bifrontal and parasagittal generalized periodic epileptiform discharges. although some of the bifrontal discharges have triphasic features but, given their evolution, these are most likely related to earlier epileptiform activity. these findings are indicative of focal cortical irritability and potential epileptogenicity predominantly in the bifrontal regions. in addition, the background is diffusely slow and disorganized indicative of moderate to severe encephalopathy. compared to the prior day's recording, there is improvement with fewer blunted discharges and longer periods of disorganized theta activity without bifrontal discharges. radiology mr head w & w/o contras 1. unchanged ventriculomegaly with associated cerebellar atrophic changes, with no evidence of transependymal migration of csf. scattered foci of high signal intensity are identified in the subcortical and periventricular white matter, likely consistent with chronic microvascular ischemic changes. 2. chronic hydrocephalus, possibly communicating, is a consideration, there is no evidence of leptomeningeal enhancement to suggest arachnoiditis, the possibility of a dandy-walker variant is also a consideration. 3. unchanged opacity of the ethmoidal air cells and sphenoid sinus suggesting an ongoing inflammatory process. cardiovascular echo poor image quality. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. the rv is not well seen but overall normal free wall contractility is probably normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. neurophysiology eeg this is an abnormal continuous icu monitoring study because of frequent generalized periodic epileptiform discharges (gpeds) at times as frequent as one to two per second. these do not evolvefurther into non-convulsive status epilepticus. however, these findings are indicative of severe cortical irritability and potential epileptogenicity in a generalized distribution. the backgroundtowards the later portion of the recording is diffusely slow and disorganized indicative of moderate to severe encephalopathy. radiology bilat lower ext veins no evidence of deep venous thrombosis in either lower extremity. the study and the report were reviewed by the staff radiologist . radiology ct head w/o contrast 1. no evidence for intracranial hemorrhage or other definite acute process. 2. moderate enlargement of all ventricles, more striking than background cerebral atrophic changes, although cerebellar atrophy is substantial. there is no hypodensity about the ventricles to suggest transependymal edema. correlation with clinical history is recommended and comparison to prior head ct, if available, may be helpful to assess for chronicity. major differential considerations include chronic hydrocephalus, probably communicating, associated with a prior inflammatory process such as arachnoiditis or perhaps in association with a congenital lesion such as dandy-walker variant. 3. opacification of the left sphenoid sinus with bony thickening suggesting longer chronicity and hyperdense material suggestive of fungal colonization. blood: 12:54pm blood wbc-20.3* rbc-4.26 hgb-13.0 hct-38.2 mcv-90 mch-30.4 mchc-33.9 rdw-12.6 plt ct-242 01:15pm blood wbc-15.5* rbc-3.44* hgb-10.1* hct-29.0* mcv-84 mch-29.5 mchc-35.0 rdw-13.1 plt ct-210 03:09am blood wbc-15.3* rbc-3.38* hgb-9.8* hct-28.3* mcv-84 mch-29.0 mchc-34.6 rdw-13.1 plt ct-272 02:15am blood wbc-17.6* rbc-3.55* hgb-10.3* hct-30.6* mcv-86 mch-29.0 mchc-33.7 rdw-13.1 plt ct-457* 05:20am blood wbc-10.8 rbc-3.24* hgb-9.4* hct-26.5* mcv-82 mch-29.1 mchc-35.5* rdw-13.5 plt ct-456* 05:16am blood wbc-13.9* rbc-3.29* hgb-9.9* hct-27.5* mcv-84 mch-30.1 mchc-36.1* rdw-14.0 plt ct-485* 01:15pm blood pt-13.3* ptt-31.9 inr(pt)-1.2* 04:31am blood pt-12.1 ptt-37.4* inr(pt)-1.1 12:54pm blood glucose-149* urean-30* creat-0.8 na-145 k-3.7 cl-112* hco3-18* angap-19 03:41am blood glucose-125* urean-10 creat-0.2* na-142 k-3.2* cl-106 hco3-29 angap-10 03:09am blood glucose-131* urean-9 creat-0.3* na-144 k-3.7 cl-101 hco3-35* angap-12 03:40am blood glucose-135* urean-15 creat-0.4 na-137 k-4.2 cl-100 hco3-24 angap-17 05:20am blood glucose-112* urean-6 creat-0.4 na-141 k-2.9* cl-104 hco3-27 angap-13 05:16am blood glucose-100 urean-7 creat-0.3* na-141 k-3.8 cl-105 hco3-29 angap-11 12:54pm blood alt-18 ast-30 ld(ldh)-367* ck(cpk)-171 alkphos-92 amylase-111* totbili-0.4 01:15pm blood alt-18 ast-29 ld(ldh)-360* alkphos-94 amylase-57 totbili-0.5 12:54pm blood lipase-26 12:54pm blood ck-mb-10 mb indx-5.8 ctropnt-0.06* 03:57pm blood calcium-9.1 phos-1.2* mg-1.8 03:09am blood calcium-8.9 phos-3.8 mg-1.9 05:39am blood calcium-9.0 phos-2.7 mg-1.7 05:16am blood calcium-9.1 phos-2.9 mg-1.9 03:41am blood cortsol-8.3 03:57pm blood tsh-0.84 09:09pm blood vanco-8.0* 03:40am blood vanco-32.0* 02:15am blood tobra-1.8* 08:53pm blood vanco-14.5 10:49am blood type-art po2-160* pco2-53* ph-7.31* caltco2-28 base xs-0 09:06am blood type-art po2-67* pco2-41 ph-7.34* caltco2-23 base xs--3 02:25pm blood type-art peep-5 po2-141* pco2-40 ph-7.48* caltco2-31* base xs-6 intubat-intubated 11:08am blood lactate-4.4* 12:51pm blood lactate-1.8 09:06am blood glucose-148* lactate-2.5* na-143 k-4.4 cl-115* 01:24pm blood lactate-0.7 02:25pm blood lactate-1.8 urine: 04:14pm urine color-amber appear-cloudy sp -1.012 04:14pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-mod 04:14pm urine rbc-121* wbc-62* bacteri-many yeast-none epi-1 04:14pm urine casthy-8* 10:07am urine color-straw appear-clear sp -1.008 10:07am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg csf: 03:46pm cerebrospinal fluid (csf) wbc-3 rbc-1* polys-1 lymphs-70 monos-29 03:46pm cerebrospinal fluid (csf) totprot-41 glucose-85 03:46pm cerebrospinal fluid (csf) herpes simplex virus pcr-negative 2:09 pm csf;spinal fluid source: lp #3. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. fungal culture (preliminary): no fungus isolated. viral culture (preliminary): no virus isolated. brief hospital course: principle reason for admission 67 year old female with pmh of multiple sclerosis and torticollis presenting from a long term care facility for further evaluation of altered mental status and being transferred to the icu for likely urosepsis after intubation for airway protection. active problems # urosepsis: the patient has a known neurogenic bladder from her underlying multiple sclerosis with a chronic indwelling foley. on admission, she was noted to be in septic shock with positive ua, bp of 86/40 and altered mental status. due to her unresponsive state, she was intubated and placed on a vent in the ed. her septic shock was initally treated broadly with vanco/cefepime/cipro; as further cultures came back, she was discovered to have a vancomycin sensitive enterococcus growing from blood and urine. she did not require any pressors during her hospitalization. the day prior to her discharge from the icu she was noted to have increased tan secretions, increasing wbc count, and low grade fever concerning for vap. she was initated on vap protocol with tobramycin and zosyn in addition to her vancomycin for vse. however, she was rapidly extubated and transferred to the floor with improving clinical status. all bal/sputum cx returned negative for growth and decision was made to discontinue vap coverage. pt was switched to ampicillin alone to complete a 14 day course for vse urosepsis, last dose pm, then picc line may be pulled. # respiratory failure/vap: she was intubated until 1 day prior to her discharge from the icu for concerns regarding her mental status, as well as secretions. she was also a very difficult intubation due to her torticollus. given concern for vap on in setting of with new tan secretions and leukocytosis, she was started on tobramycin and zosyn in addition to vanco on . she was also started on hyoscyamine for secretions. following discharge from the icu, patient's respiratory status was greatly improved and she was satting well on room air. given clinical improvement and negative bal cultures, vap coverage antibiotics were discontinued. pt was monitored clinically on ampicillin alone for an additional 48hrs and remained afebrile with no new respiratory symptoms, maintaining sats on ra. # altered mental status/seizures: patient noted on eeg suggestive of non-convulsive status. unclear how long patient has been having seizures. an lp was performed, which was predominately negative. patient was started on acyclovir, empirically. mri showed chronic hydrocephalus and ventriculomegaly with periventricular white matter changes. acyclovir was discontinued once csf was negative for hsv. patient became much more alert and interactive following extubation. she was maintained on keppra and risperdal was stopped. on transfer to the floor, patient was alert and oriented x3. she was discharged at her baseline mental status. # goals of care: patient a dnr/dni, confirmed in discussion with patient once extubated and lucid; son and hcp expressed interest in the patient being made do not hospitalize with palliative care. as of now, patient may be rehospitalized, but the facility should contact prior to transferring her to hospital. was advised to follow up with facility if the patient decides those are her wishes. #. sinus tachycardia. patient had sinus tachycardia into the 120s while in the icu. patient was placed on lower dose metoprolol 37.5 mg tid while in the icu. prior to discharge, metoprolol was increased to her home dose of 150mg daily and hr remained in the 80s. # ct read of fungal sinusitis: per ent, ct was suggestive of a chronic process and not invasive fungal disease. ent recommended an outpatient follow-up for possible resection if symptomatic. currently, fungal ball is not symptomatic. chronic problems # hydrocephalus: chronic, no changes during hospitalization. #. multiple sclerosis. the patient has severe multiple sclerosis with resultant muscle contractures; she has been wheelchair bound since , and has a neurogenic bladder requiring chronic foley. we continued her on some of her home medications, but not all given concerns for her mental status. her baclofen was decreased to 5mg tid, and her bethanechol was discontinued. #. chronic pain. seemingly related to contractures from underlying multiple sclerosis. patient denied pain during her stay. we continued her on a lidoderm patch prn but have been holding her home ibuprofen, ms contin, tramadol, gabapentin and voltaren gel. she was doing well on this minimized regimen and may not need this additional medications going forward. #. htn. held home lisinopril while in icu in setting of urosepsis. after transfer to the floor, her home dose of lisinopril was restarted. metoprolol was also started at a lower dose (37.5 mg tid) until uptitration to her home dosing of 150mg toprol daily prior to discharge. #. osteoporosis. held home alendronate. continued calcium supplementation. #. constipation. continued home docusate, senna, miralax. #. depression: had been holding home medications given intubation and altered mental status. discontinued risperdol and tramadol given they can lower seizure threshold. we also held her abilify and trazadone. we continued her citalopram. medication changes start keppra 750mg po bid start ampicillin 2 iv q4 to complete 2 weeks decrease baclofen to 5mg tid stop bethanechol stop morphine stop tramadol stop gabapentin stop risperdal stop trazodone stop voltaren transitional issues -made a number of adjustments to her psychiatric and pain medications. would monitor closely -will need to complete 14 days of ampicillin to treat urosepsis -patient with apparent fungal ball in sinus on ct. currently asymptomatic. would continue to monitor. -please talk to hcp and son before any major changes to patient's goals of care ***if patient becomes febrile, develops productive cough or worsening respiratory status, low threshold to initiate vancomycin and pip/tazo for 7 day course for hcap treatment.*** medications on admission: - alendronate 70mg weekly on monday - asa 81mg daily - baclofen 10mg tid - bethanechol 50mg qid - calcium carbonate 500mg tid - cranberry 475mg daily - docusate 200mg - fish oil daily - fleet enema rectally every day prn constipation - loratadine 10mg daily - fiber daily - metoprolol succinate 150mg daily - multivitamin daily - miralax 17 grams twice daily - selenium 200mcg - senna 4 tabs twice daily every other day - vitamin b complex daily - vitamin c 500mg daily - vitamin d 1000 units daily - ibuprofen 600mg tid - lidoderm 5% patch topically to sternum (12 hrs on/12 hrs off) - tylenol 1000mg three times daily - morphine er 30mg - tramadol 75mg every 6 hours prn pain - abilify 2.5mg at bedtime - citalopram 40mg daily - gabapentin 100mg every morning - gabapentin 300mg at 2pm and 8pm - risperdal 0.5mg prn agitation - trazodone 100mg at bedtime - voltaren 1% gel to chest every 4 hours prn pain - lisinopril 10mg daily - flaxseed oil 1000mg daily discharge medications: 1. alendronate 70 mg tablet sig: one (1) tablet po once a week: on monday. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. baclofen 10 mg tablet sig: 0.5 tablet po tid (3 times a day). 4. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po three times a day. 5. cranberry 475 mg capsule sig: one (1) capsule po once a day. 6. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 7. fish oil oral 8. fleet enema 19-7 gram/118 ml enema sig: one (1) enema rectal once a day as needed for constipation. 9. loratadine 10 mg tablet sig: one (1) tablet po once a day as needed for allergy symptoms. 10. fiber supplement powder oral 11. metoprolol succinate 50 mg tablet extended release 24 hr sig: three (3) tablet extended release 24 hr po once a day. 12. multivitamin tablet sig: one (1) tablet po once a day. 13. miralax 17 gram/dose powder sig: one (1) pack po twice a day as needed for constipation. 14. selenium 200 mcg capsule sig: one (1) capsule po once a day. 15. senna 8.6 mg capsule sig: four (4) capsule po every other day. 16. b complex vitamins capsule sig: one (1) cap po daily (daily). 17. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 18. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 19. ibuprofen 600 mg tablet sig: one (1) tablet po three times a day as needed for pain. 20. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 21. acetaminophen 500 mg capsule sig: two (2) capsule po three times a day. 22. citalopram 40 mg tablet sig: one (1) tablet po once a day. 23. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 24. levetiracetam 750 mg tablet sig: one (1) tablet po twice a day. 25. ampicillin sodium 2 gram recon soln sig: one (1) recon soln intravenous every four (4) hours for 3 days: last dose 3/8 pm. discharge disposition: extended care facility: for living discharge diagnosis: sepsis from a urinary source status epilepticus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear ms. , it was a pleasure taking care of you at . you were admitted because you had a severe urinary tract infection which led to persistent seizures. you were treated in the intensive care unit, and you were intubated for several days. you were started on iv antibiotics to treat your infection and started on levetiracetam (keppra) to control the seizures. once these were controlled, you were transferred to the floor, and we watched you for a few days while we adjusted your medications. at this time, it is safe for you to return home. you should follow up with your neurologist as scheduled below. please note the following changes to your medications: start keppra 750mg po bid start ampicillin 2 iv q4 to complete 2 weeks decrease baclofen to 5mg tid stop bethanechol stop morphine stop tramadol stop gabapentin stop risperdal stop trazodone stop voltaren followup instructions: location: , bldg address: 131 ornac , , ma phone: provider: , neurology appt: at 11am procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung enteral infusion of concentrated nutritional substances diagnoses: other chronic pain obstructive hydrocephalus urinary tract infection, site not specified toxic encephalopathy unspecified essential hypertension severe sepsis constipation, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other specified cardiac dysrhythmias alkalosis septic shock grand mal status diarrhea do not resuscitate status urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure multiple sclerosis scoliosis [and kyphoscoliosis], idiopathic ventilator associated pneumonia streptococcal septicemia other and unspecified mycoses arthrodesis status infection and inflammatory reaction due to indwelling urinary catheter neurogenic bladder nos other fluid overload mechanical complication due to urethral (indwelling) catheter torticollis, unspecified 

Answer: The patient is high likely exposed to