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: benzodiazepines / augmentin attending: chief complaint: abdominal pain major surgical or invasive procedure: left-sided nephrostomy tube placement picc line placement history of present illness: 68yo man with end-stage multiple sclerosis with suprapubic foley comes in from with two days of fevers and one day of abdominal pain and nausea. yesterday he had a fever to 102. wbc of 14.6 with 89% pmn's. txfd to for further evaluation. . in the ed, initial vs were: t 98 p 91 bp 122/63 r 20 o2 sat 95%ra. ua positive large leuks, mod bact, 87 wbcs. ct abdomen consistent with syndrome and possible pyelo, ? staghorn calculus. surgery was consulted, who recommended admission to medicine. patient was febrile to 102 and was given tylenol and vanc/zosyn for broad coverage of pyelonephritis. given 2l fluids. there were problems with venous access - anatomy made an ij difficult (pt contracted), and two attempts at a r subclavian were c/b air in the syringe, then arterial puncture. pressure held x15 minutes, no ptx on cxr. a right femoral line was placed. troponin 0.08 and pt had ? new q waves inferiorly in iii/avf with twi in v2/v3, and rectal aspirin given. transferred to the floor . on the floor, the patient has low pelvic abdominal pain. trouble clearing secretions. past medical history: 1. ms, endstage secondary progressive type. 1. decubitus ulcer (healing). 2. history of lung aspiration and lung abscess. 3. hypertension. 4. gastroesophageal reflux. 5. status post gastrostomy tube. 6. status post suprapubic catheter. social history: lives in nursing home at , divorced, two children. retired biochemist. denies etoh/tobacco/drugs. family history: non-contributory. physical exam: admission exam: vitals: t: 99 bp: 115/68 p: 79 r:21 o2: 97 general: alert, oriented. heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp difficult to assess lungs: anterior/lateral auscultation has poor inspiratory effort with coarse breath sounds and some rhonchi bilaterally. cv: distant heart sounds. regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: distended firm abdomen. tympanic to percussion. g-tube in place as well as suprapubic catheter in place. nt to palpation. no organomegaly appreciated. gu: clear urine ext: atrophic lower extremities. warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema neuro: quadraplegic. aox3. movement of right shoulder and can move eyes. discharge exam: generally unchanged from admission. abdomen distended but soft, and non-tender with normoactive bowel sounds. discharge vs: 98.5, 114/70, 78, 26, 93% ra. pertinent results: admission labs 08:12pm urine hours-random 08:12pm urine gr hold-hold 08:12pm urine color-yellow appear-hazy sp -1.033 08:12pm urine blood-sm nitrite-pos protein-100 glucose-300 ketone-neg bilirubin-neg urobilngn-neg ph-7.5 leuk-lg 08:12pm urine rbc-9* wbc-87* bacteria-mod yeast-none epi-<1 08:12pm urine hyaline-1* 08:12pm urine mucous-rare 03:55pm pt-12.3 ptt-25.5 inr(pt)-1.0 03:28pm lactate-1.9 03:15pm glucose-309* urea n-24* creat-0.8 sodium-126* potassium-4.2 chloride-89* total co2-27 anion gap-14 03:15pm estgfr-using this 03:15pm alt(sgpt)-44* ast(sgot)-19 ck(cpk)-33* alk phos-157* tot bili-0.8 03:15pm lipase-17 03:15pm ctropnt-0.08* 03:15pm ck-mb-2 03:15pm calcium-8.5 phosphate-2.4* magnesium-2.3 03:15pm wbc-13.5* rbc-4.47* hgb-13.2* hct-38.3* mcv-86 mch-29.6 mchc-34.6 rdw-16.5* 03:15pm neuts-87.9* lymphs-7.6* monos-3.8 eos-0.4 basos-0.4 03:15pm plt count-134* other pertinent labs: 04:00am blood alt-58* ast-48* ld(ldh)-148 alkphos-256* totbili-0.7 05:33am blood alt-46* ast-27 ld(ldh)-135 alkphos-265* totbili-0.6 03:15pm blood ctropnt-0.08* 12:38am blood ctropnt-0.11* 07:56am blood ck-mb-2 ctropnt-0.14* 03:11pm blood ck-mb-3 ctropnt-0.09* 03:50am blood ck-mb-2 ctropnt-0.04* 05:33am blood albumin-2.5* calcium-8.0* phos-2.7 mg-1.8 12:38am blood osmolal-281 05:33am blood vanco-17.4 discharge labs: 04:37am blood wbc-9.4 rbc-3.46* hgb-10.0* hct-30.3* mcv-88 mch-29.1 mchc-33.1 rdw-16.3* plt ct-211 04:37am blood glucose-160* urean-12 creat-0.4* na-141 k-4.4 cl-102 hco3-33* angap-10 04:37am blood alt-37 ast-17 alkphos-228* totbili-0.5 04:37am blood calcium-8.3* phos-2.6* mg-1.8 microbiology: urine culture : proteus mirabilis | providencia stuartii | | morganella morganii | | | enterococcus sp. | | | | enter | | | | | amikacin-------------- 4 s 4 s ampicillin------------ =>32 r <=2 s <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s <=1 s 32 r ceftazidime----------- <=1 s <=1 s =>64 r ceftriaxone----------- <=1 s <=1 s =>64 r ciprofloxacin--------- 2 i =>4 r 1 s gentamicin------------ =>16 r s <=1 s meropenem-------------<=0.25 s <=0.25 s <=0.25 s nitrofurantoin-------- 256 r 256 r <=16 s <=16 s tetracycline---------- =>16 r =>16 r tobramycin------------ =>16 r i <=1 s trimethoprim/sulfa---- =>16 r <=1 s <=1 s vancomycin------------ 1 s 1 s . blood culture : negative blood culture : gpcs in pairs and chains urine culture : negative imaging: cxr : 1. bibasilar opacities could reflect aspiration or atelectasis. 2. right costophrenic angle blunting could reflect pleural thickening given chronicity of appearance. ct abd/pelvis : 1. large staghorn calculus in the left renal pelvis, new from ct. possible mild pyelitis though no overt signs of pyelonephritis. suprapubic catheter in place with apparent bladder wall thickening, correlate for infection. 2. mild dilation of the redundant sigmoid colon without distal obstruction -likely syndrome. mild fecal rectal impaction. 3. stable hepatic hemangioma. 4. bibasilar opacities in the lungs, likely atelectasis or aspiration. cxr : interval changes suggest interval development of chf with interstitial edema. cxr : a right subclavian picc line is present, tip over distal svc near svc/ra junction. no pneumothorax is detected. otherwise, i doubt significant interval change. unilat up ext veins us right : no evidence of dvt in the right upper extremity. tte : the left atrium is moderately dilated. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse or regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. the effusion appears circumferential. impression: suboptimal image quality. preserved regional and global biventricular systolic function. very small circumferential pericardial effusion. brief hospital course: #) sepsis secondary to pyelonephritis/bacteremia: patient with endstage ms suprapubic cath presented with fevers, tachycardia, and leukocytosis with dirty ua. ct abdomen was concerning for struvite stone in left kidney. he was initially admitted to micu w/sepsis requiring fluid boluses and pressors, and was empirically started on vancomycin/zosyn for broad coverage. stablizied and was off pressors since . urology consulted with no recommendations for change in suprapubic catheter exchange (recently replaced 2 weeks prior to presentation per report), though did recommend percutaneous nephrostomy tube placement. patient had ir placement of left nephrostomy tube on , and had adequate urostomy drainage and improvement in hemodynamics/leukocytosis/fevers by post intervention day 2. patient likely has colonization of resistant bacteria from his suprapubic foley, though acute infection occurring now in setting of left kidney staghorn calculus. urine culture positive for proteus mirabilis, providencia stuartii, morganella morganii, and vanc-sensitive enterococcus. per urology, would have high suspicion that proteus was responsible for much of acute infection, as this bacteria is known to cause calculi. patient was continued on vanc/zosyn but was switched to vanc/ertapenem on , and per urology recs patient should continue on this regimen through urology follow-up appt on . will likely need surgical management of left staghorn calculi at that time. left nephrostomy tube should remain in place and open to drainage until urologyg follow-up. of note, blood cultures from positive for gpcs in pairs and chains, though speciation still pending at time of discharge. tte was suboptimal but did not show evidence of vegetations. patient already on >2 week course of broad spectrum abx. #) hypoxia: patient not on o2 at baseline, though was requiring 5l nc suppplemental o2 on arrival to floor following icu stay. cxr showed e/o effusions and interstitial edema, as well as probable atalectasis. suspected volume overload following icu course with ivf and pressor administration in setting of sepsis. echo showed preseved systolic function with ef >55. also be component of aspiration, and per speech and swallow evaluation patient should only have ice chips with supervision, otherwise strict npo. patient diuresed with 20mg iv furosemide on , and was net negative 2.1l with improvement in o2 sat to 93% on ra. o2 sats should be monitored on discharge, and patient should continue on albuterol/ipratropium nebs q6h prn cough/wheeze/sob. will require suctioning of secretions, and should be npo with all meds given via g-tube. #) apnea/transient desaturation: likely secondary to patient's neuromuscular disease/ms and inability to clear secretions. patient failed multiple trials of cpap while in the icu, though was able to tolerate cpap on floor. will need outpatient sleep study once discharged. #) afib with rvr: patient with new onset afib with rvr to 140s in the setting of transient apnea and desaturations. patient was started on metoprolol tartrate 12.5 tid. his episodes spontaneously resolved after 5-10 minutes, and he coverted back to nsr. for chads2 score 0-1, was started on aspirin 81 mg. echo showed moderate la enlargement. #) abdominal pain/distention with 1 week's worth of constipation: imaging consistent with syndrome, which can be a complication of multiple sclerosis as well as oxybutynin use. dc'd anticholinergics and started aggressive bowel regimen with good results. no evidence of perforation on imaging. patient was not restarted on oxybutynin on discharge. #) positive troponin on admission: likely strain as ck-mb was flat. there are ekg changes relative to previous ekg from , but clinical picture more consistent with strain than acs. echo showed preserved systolic function. #) multiple sclerosis: held oxybutynin per above but continued baclofen. will need suctioning of oral secretions. labs/studies pending at time of discharge: blood culture : speciation of gpcs issues requiring follow-up: -patient with new onset afib this admission and was started on metoprolol for rate control and asa 81mg daily. will need outpatiet follow-up -patient should continue on aggresive bowel regimen and discuss with pcp whether he should restart oxybutynin -patient's fsbs were elevated this admission in setting of acute infection, and should be monitored in outpatient setting -patient may benefit from outpatient sleep study given concern for sleep apnea, may also benefit from cpap at night if patient will tolerate medications on admission: - oxybutynin er 10mg daily - simvastatin 80mg daily - metoclopramide 5mg qid - omeprazole 20mg daily - provigil 200mg daily - bisacodyl 10mg suppository qhs - baclofen 10mg q12am/12pm, 15mg q6am/6pm - natural balance tear drops 2 drops ou q8hrs - levothyroxine 50mcg daily - acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain - fleet enema 19-7 gram/118 ml enema sig: one (1) enema rectal once a day as needed for constipation - albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation every six (6) hours as needed for cough, wheezing, or shortness of breath - ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for cough, wheezing, or shortness of breath. - multivitamin liquid sig: fifteen (15) ml po once a day. - guiatuss 100 mg/5 ml liquid sig: ten (10) ml po every six (6) hours as needed for cough. - milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml po once a day as needed for constipation. - magnesium citrate solution sig: 0.5 bottle po monday, wednesday, friday. - enulose 10 gram/15 ml solution sig: fifteen (15) ml po every six (6) hours: given on tuesday, thursday, saturday, sunday. discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. metoclopramide 5 mg tablet sig: one (1) tablet po four times a day. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. provigil 200 mg tablet sig: one (1) tablet po once a day. 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime). 6. baclofen 10 mg tablet sig: one (1) tablet po bid (2 times a day): given at 12 am and 12 pm. 7. baclofen 10 mg tablet sig: 1.5 tablets po bid (2 times a day): given at 6 am and 6 pm. 8. natural balance 0.4 % drops sig: two (2) drop ophthalmic every eight (8) hours. 9. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 10. acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain. 11. fleet enema 19-7 gram/118 ml enema sig: one (1) enema rectal once a day as needed for constipation. 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation every six (6) hours as needed for cough, wheezing, or shortness of breath. 13. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for cough, wheezing, or shortness of breath. 14. multivitamin liquid sig: fifteen (15) ml po once a day. 15. guiatuss 100 mg/5 ml liquid sig: ten (10) ml po every six (6) hours as needed for cough. 16. milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml po once a day as needed for constipation. 17. magnesium citrate solution sig: 0.5 bottle po monday, wednesday, friday. 18. enulose 10 gram/15 ml solution sig: fifteen (15) ml po every six (6) hours: given on tuesday, thursday, saturday, sunday. 19. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 20. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 21. ertapenem 1 gram recon soln sig: one (1) gram intravenous daily () for 6 days. 22. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 6 days. 23. picc line orders heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care facility: - discharge diagnosis: primary: sepsis secondary to pyelonephritis and bacteremia secondary: multiple sclerosis, pulmonary edema, atrial fibrillation, ??????s syndrome discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: mr. , it was a pleasure taking care of you during your stay at . you were initially admitted to the icu with fevers and abdominal pain. we found you had a urinary tract infection/kidney infection, due to a large stone in your left kidney. you were seen by the urologists, who recommended you have a tube placed to help drain urine from the left kidney while the stone is causing an obstruction. we started you on antibiotics, and gave you iv fluids and medications to help raise your blood pressure. you improved with these treatments and were stable for transfer to the medicine floor. the urologists recommend you continue on iv antibiotics for another 2 week course. they will see you in the clinic after the infection has resolved, to discuss what the next steps are to treat the kidney stone. the tube in your kidney will remain in place until that appointment. while you were here, you heart also went in and out of an abnormal rhythm called atrial fibrillation. we started you on an aspirin, and also a medication to control your heart rate. we made the following changes to your medications: 1. started aspirin 81mg daily 2. started metoprolol 12.5mg tid 3. started vancomycin 1gm iv q12h (through ) 4. started ertapenem 1gm daily (through ) 5. stopped oxybutynin (please discuss whether you should restart this medication with your pcp) we did not make any other changes to your medications. please continue to take them as you have been doing. followup instructions: department: surgical specialties when: wednesday at 9:00 am with: urology unit building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances percutaneous nephrostomy without fragmentation non-invasive mechanical ventilation diagnoses: obstructive sleep apnea (adult)(pediatric) esophageal reflux unspecified essential hypertension severe sepsis atrial fibrillation other specified intestinal obstruction septic shock multiple sclerosis hydronephrosis streptococcal septicemia calculus of kidney infection and inflammatory reaction due to indwelling urinary catheter pyelonephritis, unspecified neurogenic bladder nos 

Answer: The patient is high likely exposed to