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: patient recorded as having no known allergies to drugs attending: chief complaint: sepsis major surgical or invasive procedure: central line placement x2 (femoral and r subclavian) picc placment and repositioning history of present illness: 57 yo m recent discharge from to rehab, now returns with tachycardia, hypotension and increasing lethargy/malaise and increasing wbc. pt is positive for c diff, on po flagyl. en route to , bp dropped to 70s so diverted to , where better access was obtained and an a-line was placed. he received 3500cc crystalloid with improvement in his bp and he was transferred to . recent admission to this hospital with fever, leukocytosis and hypotension, eventually dx'd with c diff and placed on po vanco. urine cx returned yesterday with pseudomonas resistant to cipro. in the ed here, vs: 97.9, 100/44, 76, 16, 100% a femoral cvl was placed. levophed was started. he received vanco, zosyn, and flagyl after cx obtained. on arrival to the micu pt indicates that he feels better. past medical history: ++ pneumonia - - respiratory failure, intubation, tracheostomy ++ acalculous cholecystitis - percutaneous cholecystostomy tube - percutaneous tube dislodgement --> fever leukocytosis - fever leukocytosis --> ercp ( ) w/ stent - open cholecystectomy @ ++ diabetes mellitus, insulin dependent ++ atrial fibrillation ++ congestive heart failure ++ chronic renal insufficiency ++ mrsa ++ cdiff ++ hx esbl-klebs past surgery history - trach/eg - cholecystostomy tube on , tube replaced on social history: rehab since admission in . used to live with his children, taxi driver, divorced, 2 children. family history: mother healthy; father with mi. physical exam: admission physical exam vs: 96.7 81 136/61 18 100% on ac gen: chronically ill appearing : perrl neck: trach in place heart: s1s2 rrr pulm: coarse bs bilaterally abd: +bs, soft, mild ttp diffusely, ext: trace edema back: + sacral decubiti, packed rectal: guaiac negative brown stool neuro: alert, awake, follows commands, mae pertinent results: admission labs: 11:00pm wbc-21.1* rbc-2.89* hgb-8.5* hct-26.5* mcv-92 mch-29.4 mchc-32.1 rdw-15.0 11:00pm neuts-89.7* lymphs-5.1* monos-1.6* eos-3.3 basos-0.3 11:00pm glucose-261* urea n-26* creat-1.2 sodium-135 potassium-4.7 chloride-98 total co2-27 anion gap-15 11:35pm glucose-245* lactate-2.2* na+-134* k+-4.7 cl--98* tco2-28 11:00pm alt(sgpt)-24 ast(sgot)-46* ck(cpk)-24* alk phos-391* tot bili-0.3 11:00pm lipase-8 11:00pm tot prot-5.6* calcium-7.9* phosphate-3.8 magnesium-1.7 11:00pm pt-15.7* ptt-40.6* inr(pt)-1.4* wbc trend: 03:36am blood wbc-27.1* rbc-2.74* hgb-7.9* hct-25.1* mcv-92 mch-28.9 mchc-31.6 rdw-14.7 plt ct-245 04:22am blood wbc-14.5* rbc-2.88* hgb-8.2* hct-25.7* mcv-89 mch-28.5 mchc-32.0 rdw-15.5 plt ct-195 05:48am blood wbc-10.2 rbc-2.79* hgb-8.2* hct-24.9* mcv-90 mch-29.3 mchc-32.7 rdw-15.7* plt ct-182 06:40am blood wbc-12.5* rbc-3.13* hgb-9.3* hct-27.8* mcv-89 mch-29.7 mchc-33.4 rdw-15.4 plt ct-193 05:50am blood wbc-12.0* rbc-3.42* hgb-9.8* hct-30.9* mcv-91 mch-28.7 mchc-31.7 rdw-15.2 plt ct-208 discharge labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw pltct 07:46am 9.6 3.07* 9.3* 27.1* 88 30.2 34.3 15.8* 196 07:46am pt, ptt, inr, plt ct: 14.5*, 39.4*, 1.3*, 196 chemistry renal & glucose glucose urean creat na k cl hco3 angap 09:41am 136* 11 0.4* 138 3.3 107 25 9 micro: 5:44 pm sputum source: endotracheal. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): oropharyngeal flora absent. yeast. rare growth. . 11:00 pm blood culture site: arm **final report ** blood culture, routine (final ): no growth. . 11:45 pm blood culture site: central line central line-x2. blood culture, routine (pending): . 12:45 am urine site: catheter **final report ** urine culture (final ): no growth. . radiographic studies: . ct chest/abd/pelvis: impression: 1. no cause for the patient's sepsis identified. no intra-abdominal or intrapelvic abscess. no evidence of pneumonia. 2. small bilateral pleural effusions and bibasilar atelectasis. 3. sacral decubitus ulcer with slightly increased gas in the subcutaneous tissues to the right of the coccyx. it is unclear if this increased gas is related to progressive infection or manipulation/debridement. clinical correlation is recommended. . portable chest, comparison: comparison study of one day earlier. indication: possible pneumonia. findings: indwelling devices are in standard position, and cardiomediastinal contours are unchanged. lower lung volumes result in crowding of bronchovascular structures, limiting assessment of volume status of the patient. increasing patchy opacities at both bases may be due to atelectasis, but attention to these areas on repeat radiograph with improved inspiratory level may be helpful. left-sided loculated fluid versus pleural thickening is unchanged. . history: 57-year-old man, now status post placement of new picc line, assess for placement. comparison: . ap portable chest radiograph: the left-sided picc line is seen curled around in the axillory region. the right subclavian central venous line is in unchanged position with the tip at the mid svc. the patient is status post tracheostomy, but the apparatus is seen without apparent complications. there is persistent low lung volume, with appearance of crowding of bronchovascular structures. the previously noted left side opacity is unchanged and also suggestion of left- sided fluid vs. pleural thickening. left upper extremity duplex ultrasound dated : impression: thrombosis of the cephalic vein in the region of the existing picc line. no deep venous thrombosis. brief hospital course: 57m with mmp returning from rehab with rising wbc and hypotn, concerning for sepsis. # hypotension: most likely cause in setting of leukocytosis and recent infections is recurrence of sepsis (most likely urine, but other possible sources include c diff, pneumonia, sacral decubiti). no evidence of cardiogenic shock cardiac ischemia based on 12-lead; no indication of hemorrhage (guaiac neg). in the ed had right femoral line placed, was volume resuscitated and started on levophed. upon arrival in the icu, he was continued on volume resuscitation and he pressors were ulimately weaned the day of admission. given his history of cipro resistent pseudomonas and esbl klebsiella, he was empirically started on meropenum / vancomycin with flagyl given history of c.diff. on , a right subclavian line was placed and a ct torso was obtained to evaluate for potential source but was unrevealing. once hemodynamically stable, he was transferred to the floor for continued care. patient remained stable on the floor. sputum culture showed yeast, all other cultures negative. plastic surgery examined sacral wound and felt was healing well, unlikely source of infection. iv vanco was d/c. iv flagyl also d/c after pt had decreased bm and wbc remained around 12 and patient remained afebrile with stable vital signs. # cdiff: cdiff pos x3 during last admission. pt started on iv flagyl upon admission in setting of sepsis, which was d/c on . at time of d/c the patient is not having any diarrhea. pt remains on po vanco and should do so until 2 weeks after d/c meropenem. if diarrhea continues at this point, repeat cdiff studies and additional stool studies may be warrented. # urinary tract infection: prior culture from last hospitalization revealed pseudomonas, resistant to cipro, which is what the patient had been sent to rehab on. new urine culture was sent and he was changed to meropenem which should be continued to complete a 14 day course. his foley was d/c on anticipation of d/c because patient aaox3 and states able to use urinal. # respiratory failure: upon admisison, was placed on ac ventilation in ed, but patient stated he is not vent-dependent. he was quickly transitioned to pressure support settings and then back to his home trach mask. upon transfer from micu, pt had a speech and swallow evaluation for both diet modifications and pass??????-muir valve evaluation. patient tolerated pmv and his diet was advanced as per ss recommendations. he developed a productive cough while on the floor and was started on chest pt and guaiffenesin syrup, along with his albuterol nebs and ipratroprium mdi. pt has been 97-100% on tm for several days before d/c. # atrial fibrillation: upon admission was in sinus and on sotalol. sotolol was initially held given hypotension, but was restarted . records obtained from initial hospitalization in at hospital indicated that patient had a single isolated episode of afib w/rvr in the setting of complicated pneumonia w/demand ischemia which resolved on carizem drip. pt had been on warfarin on d/c from but was taken off at some point between his d/c on and his admission to in early , likely for surgical interventions for his cholecystitis. after speaking with the family, it appeared that the patient actually had had several periods of atrial fibrillation including after cardioversion. with this additional history, we made the decision to start the patient on coumadin at 5mg per day with a lovenox bridge, which was started at 100 q12h. he will need his inr checked and his coumadin level adjusted accordingly. the patient should have cardiology f/u at some point to further address this issue as well as consider an outpatient stress test when clinically improved (based on echo during prior admission which showed mild lv dysfunction). # sacral decubiti: currently receiving dressing changes tid at rehab. underwent debridement in early . per prior plastics recommendations, patient was continued on wound care tid and placed on a kinair bed. patient was evaluated by the prs service after transfer to the floor who recommended wet to dry dressing changes, nutritional optimizaiton, frequent turning, and f/u at prs resident clinic in 2 months for re-evaluation. they did not feel that his ulcer was a source of infection and felt that it appeared to be healing well. # diabetes mellitus: on lantus and iss as an outpatient. lantus held on admission while holding tubefeeds. started on insulin gtt for glucose control, which was then discontinued once his condition improved. on , his glargine was restarted. it was increased from 20u qhs to 25u qhs on after several high bs (mostly low to mid 200's) requiring iss coverage. # fen: the patient was started on tf until evaluated by s&s on who recommended a modified diet and instructions regarding feeding including: 1:1 observation, sitting upright while eating, single cup sips only consistency: pureed (dysphagia); nectar prethickened liquids, pills via peg. pmv in place for all pos. when he is taking adequate pos the patient's tf may be d/c. # iv access: the patient initially had a femoral line placed in the ed which was switched for a r subclavian in the micu which was switched for a l picc line on the floor on . an us was performed for concern for dvt in the lue which was positive for thrombosis in the cephalic vein (in which the catheter was placed). the l sided picc was pulled and a r sided picc was placed. at this point his r subclavian line was pulled by ir. the decision was made not to anticoagulate the patient for the cephalic vein thrombosis as it is not considered a dvt, however, the patient was placed on therapeutic lovenox as a bridge to anticoagulation with coumadin for his atrial fibrillation. # code - full code medications on admission: - vanco 125 po q 6 - heparin 500 tid - famotidine 20 - albuterol neb prn - humalog ss - sotalol af 80 tab - mvi - citalopram 20 2 tabs qd - zinc 220 po qd - vit c 500 sr - tylenol 325 q 4-6 prn - glargine 20 units qhs - alprazolam 1mg prn - oxycodone 5mg q 4-6 prn - cipro 1 tab po bid discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane (2 times a day). 2. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours): please continue for 2 weeks after patient completes course of meropenem. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 4. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day) as needed for shortness of breath or wheezing. 5. ascorbic acid 90 mg/ml drops sig: one (1) po bid (2 times a day). 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 7. sotalol 80 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 9. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed. 10. insulin glargine 100 unit/ml solution sig: twenty five (25) units subcutaneous at bedtime. 11. sodium chloride 0.9 % 0.9 % parenteral solution sig: five (5) ml intravenous prn (as needed) as needed for line flush. 12. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q6h (every 6 hours) for 9 days: needs 8 more days to complete 14 day course. 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 14. warfarin 5 mg tablet sig: one (1) tablet po daily (daily). 15. enoxaparin 100 mg/ml syringe sig: one (1) ml subcutaneous q12h (every 12 hours): lovenox as bridge for anticoagulation with coumadin - can d/c once therapeutic on coumadin. ml 16. aspirin 81 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - discharge diagnosis: sepsis discharge condition: stable discharge instructions: please continue your meropenem for 9 more days to complete a 14 day course for your urinary tract infection. continue taking your oral vancomycin for 2 weeks after the meropenem is finished. if you continue to have diarrhea, your providers should re-check a cdiff test and my want to consider sending additional stool studies. we have started you on aspirin to reduce your risk of stroke and heart attack. please take this as directed. after reviewing your records and speaking with your family we have decided to start you on a blood thinning medication to prevent a stroke from your atrial fibrillation. you will need to have your inr (blood test) checked frequently while you are at your rehabilitation facility. please continue wet to dry dressings twice daily for your wound. stay off your back as much as possible to help this wound to heal. please continue to follow the dietary restrictions recommended by speech and swallow: 1. po intake of nectar thick liquids and puree. 2. pills crushed with puree or via peg tube. 3. 1:1 supervision with all pos. 4. pmv in place for all pos. 5. a) strict 1:1 supervision b) sit fully upright for all pos. c) no consecutive sips of liquid - single sips via cup only. no straws. e) alternate between each bite and sip 6. q6 oral care. 7. patient awaiting d/c to rehab and recommend continued monitoring and dysphagia therapy. suggest an instrumental evaluation (mbs) prior to upgrading patient's diet, h/o silent aspiration of thin liquids. please continue to work with a social worker once at to help you cope through this difficult time. please take your medications as prescribed. please return to the ed if you develop fevers, chills, are vomiting and unable to tolerate pos, chest pain, shortness of breath, or any other concerns. followup instructions: please call the plastic surgery clinic at to schedule a follow up appointment in resident clinic in 2 months. we have scheduled an appointment for your with your surgeon, dr because you missed your appointment during this visit. your new appointment is for , at 11:45. you can call if you need to reschedule this appointment. please also keep your appoinment with dr . on ay 10:00. please call if you need to reschedule this appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances diagnoses: obstructive sleep apnea (adult)(pediatric) anemia, unspecified urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia severe sepsis atrial fibrillation chronic kidney disease, unspecified long-term (current) use of insulin septic shock intestinal infection due to clostridium difficile other acquired absence of organ other complications due to other vascular device, implant, and graft pressure ulcer, buttock pressure ulcer, lower back surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation gastrostomy status pressure ulcer, stage iv pseudomonas infection in conditions classified elsewhere and of unspecified site chronic respiratory failure tracheostomy status personal history of methicillin resistant staphylococcus aureus personal history, urinary (tract) infection 

Answer: The patient is high likely exposed to