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: penicillins / iodine attending: chief complaint: worsening leukocytosis major surgical or invasive procedure: t12 bilateral laminectomy, medial facetectomy, foraminotomy. far lateral transpedicular decompression bilaterally at t12. biopsy of right-sided posterior elements and sent for pathology. exploration of fusion mass t10, t11, t12. removal of hardware at t12 with cutting of the rod and extension of fusion distally. segmental instrumentation with application of dominoes and extension of the rod with pedicle screw instrumentation, l1 and l2. fusion arthrodesis t12-l1-l2. application of allograft. scar revision. history of present illness: 64 yo m with h/o dm, asthma, bipolar disorder, hypothyroidism, pcn allergy (s/p desensitization), with multiple admission for treatment of recurrent bacteremia, t9-10 epidural abscess(mssa), and empyema requiring thoracic spine decompression and decortication, found to have rise in wbc in clinic and sent to ed for further evaluation. . patient initally presented in with mssa epidural thoracic abscess with cord compression and empyema. he was also noted to have c4-5 discitis and osteomyelitis. he also had decortication of r lung for empyema. he was discharged on on nafcillin. . the pt returned two weeks later with bilateral le paralysis and found to have recurrent thoracic epidural abscess requiring emergent t8-11 laminectomy and debridement . blood cultures from revealed albicans and patient was started in fluconazle. pt returned to the or for r thoracotomy, t9-t10 corpectomy w/ anterior thoracic fusion and posterior fusion. the patient recured a chest tube a ptx. the patient continued to have low grade fevers and increased wbc. a bal was performed which showed serratia marcescens. the patient was treated for vap with 8 days of cipro. the patient had progression of cxr innfiltrate, and was started on empiric vanco, zosyn, fluconazole, which was narrowed to nafcillin, cipro, and fluconazole with negative bcx. a left thoracocentesis was performed without growth on culture. . he was then readmitted on with purulent drainage from posterior midline incision. he went to or for repeat i&d. urine cx, wound cx and 2 out of 4 bcx grew enterobacter cloacae susceptible to meropenem, gentamicin and cefepime. he was sent to rehab on iv cefipime and vancomycin, with a plan for for 8 weeks of vancomycin and at least 6 weeks of cefipime. while at rehab course has been significant for increasing wbc. at d/c his wbc was 11 and on , wbc was 17.6. he had been afebrile at rehab, but had been noted to have loose stools. work-up of leukocytosis while at rehab included per verbal report a negative cxr, negative u/a with neg le and nt and pending u cx and negative c diff. . at clinic today, pt noted to have dry mm and also with purulent drainage from posterior incision site. his bp was 92/60 t 97.5. he was sent to er for further evaluation of possible recurrent wound infection. . in er t 96.9, hr 58, 95/53 95% on ra. 95% on ra. he rec'd 2 l ns woith inecrease of bp to 95/54, and was continued on prior abx cefipime and flagyl. pt was seen by ortho who would like c-spine ct and are planning to take him to or tomorrow. past medical history: schizophrenia hypothyroidism dmii, insulin dependent hyperlipidemia asthma depression s/p epidural abscess(resistant acinetobactor) with multiple drainage procedures and paraplegia enterobactor bacteremia severe malnutrition atrial fibrillation ivc filter social history: tob: remote 30 pkyr hx; quit 20 yrs ago. no etoh. +marijuana use. no ivdu or other iv injection use. retired; former electrician. lives with son, daughter-in-law and grandson. been in and out of nursing facilities since . family history: father dm2 mother cad physical exam: vs: t 97.4 bp 132/58 p 84 98 % ra gen: white male who appears states age, sleeping, falls asleep during questioning, but answers appropriatly heent: ncat, perrl, oropharynx clear and without erythema or exudate neck: supple, no lad, no appreciable jvd cv: rrr, normal s1s2, ? 1/6 sem at usb, rubs or gallops pulm: barrel chested, ctab, no w/r/r, good air movement bilaterally abd: soft, ntnd, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated ext: warm and well perfused, full and symmetric distal pulses, no pedal edema. picc in lue c/d/i neuro: aaox3, responds appropriately to questions, cn 2-12 grossly intact. unable to move le upon command and absense sensation below hip. + perineal sensation. up going babinski b/l. pertinent results: admission labs: wbc-15.8* rbc-3.49* hgb-9.7* hct-30.4* mcv-87 mch-27.8 mchc-32.0 rdw-14.6 plt ct-854* neuts-72.4* lymphs-19.1 monos-4.3 eos-3.8 baso-0.5 pt-14.7* ptt-27.4 inr(pt)-1.3* glucose-72 urean-21* creat-0.8 na-136 k-4.9 cl-98 hco3-29 angap-14 alt-9 ast-16 ck(cpk)-26* alkphos-147* totbili-0.3 . 02:45pm blood ck-mb-notdone ctropnt-0.03* 09:35pm blood ck-mb-notdone ctropnt-0.04* 02:46pm blood ck-mb-notdone ctropnt-0.03* . 07:22am blood vanco-18.3 . wbc-10.8 rbc-3.35* hgb-9.6* hct-29.6* mcv-88 mch-28.7 mchc-32.5 rdw-14.1 plt ct-586* neuts-80.8* lymphs-12.9* monos-4.1 eos-1.9 baso-0.3 glucose-182* urean-12 creat-0.7 na-139 k-4.4 cl-99 hco3-31 angap-13 . 05:35am blood esr-125* 09:35pm blood esr-150* 02:45pm blood esr-130* . 05:35am blood vitb12-674 05:35am blood tsh-5.5* 05:35am blood t4-9.3 . 05:35am blood crp-92.0* 09:35pm blood crp-100.8* 02:45pm blood crp-118.8* . microbiology: urine culture: negative blood culture: enterobacter cloacae sensitive to cefepime, gentamicin, meropenem, tobramycin stool culture: negative . all other blood cultures: negative . wound culture: acinetobacter sensitive to amikacin, unasyn, tobramycin . c difficile toxin: negative c difficile toxin: negative c difficile toxin: negative . ct t-spine: 1. horizontal fracture of the superior endplate of t12, with posterior translation of the fracture fragment relative to the remainder of the vertebral body into the central canal. paired pedicle screws are located within this displaced fracture fragment, and is displaced along with the fragment into the central canal. 2. soft tissue bulging at the site of this fracture, presumed to represent a hematoma. however, superimposed infection cannot be excluded. 3. assessment for an abscess is limited without iv contrast. . cxr: 1. posterior migration of the two distal set of pedicle screws compared to ct chest of , with acute angulation and kyphosis of the thoracic spine at this level, concerning for unstable hardware. 2. moderate right pleural effusion with atelectasis. . echo: no endocarditis or abscess seen. normal regional and global biventricular systolic function. no pathologic valvular abnormality seen. . eeg: this is an abnormal routine eeg due to the slow background and bursts of generalized slowing. these abnormalities suggest a mild to moderate encephalopathy. medications, metabolic disturbances and infection are among the most common causes. no lateralized or epileptiform features were noted. brief hospital course: 64 yo m with h/o dm, asthma, schizophrenia, hypothyroidism, recurrent epidural abscess, t9/10 ostemyelitis and subsequent spinal cord compression with paraplegia, and severe malnutrition admitted with rising wbc count found to have enterobactor septicemia and acinetobactor osteomyelitis of t9/10. . # enterobactor bacteremia/sepsis: enterobactor sensitive to gentamicin, tobramycin, and meropenem. tte showed no sign of vegetation or abscess. patient initially treated with iv vancomycin and meropenem on admission while sensitivities were pending. he was then transitioned to iv unasyn 3gm q4h and cefepime 1gm q12 h on . due to a concern for mental status change in the setting of high dose unasyn, patient was briefly transitioned to tobramycin over 4 days and continued on cefepime. when his mental status returned to baseline, unasyn was resumed and cefepime continued on at the reommendation of the id team. patient was observed for 30 hours on the high dose unasyn without evidence of worsening delirium and discharged with plan to continue an 8 week course from . patient is to have weekly labs (cbc, chem 7, crp, esr, lfts) faxed to the following id team and follow up in their clinic as scheduled. end date for antibiotics is approximately , for patient to complete an 8-week course. . # recurrent epidural abscess/osteomyelitis at t9/10 and paraplegia: patient is s/p multiple procedures and debridements with inability to move lower extremities and persistent urinary retention. he has not regained any significant motor function in the lower extremities. during this admission, he was taken back to the or for hardware removal and washout on . tissue cultures obtained intra-op were positive for acinetobacter, sensitive to unasyn and tobra. spinal drains were discontinued on hd#5. wound care continued with daily dressing changes and patient was encouraged to not lie directly on his wound to allow for appropriate healing. patient is allowed out of bed and to participate in physical therapy with a tlso brace in place. wound care is to continue as prescribed and patient has follow up arranged with ortho spine team as scheduled. . # delirium: patient noted to have significant decline in mental status with waxing and course complicated by visual hallucinations on hospital day 4. initial concern was for worsening infection vs. metabolic abnormality vs. drug toxicity vs. seizure. patient was evaluated by the neurology team with an eeg consistent with toxic/metabolic encephalopathy. psychiatry team consulted on the patient and recommended titrating his anti-psychotics to off as they were prescribed at doses greater than typically prescribed and to start haldol in there place. given that delirium started when high dose unasyn was started, he was switched to tobramycin for concern of medication-induced delirium. patient's mental status improved over subsequent days and was back to baseline by when mitt restraints were discontinued. the patient did not develop any qtc prolongation on haldol and demonstrated no signs of anti-psychotic side-effects. unasyn was resumed as above prior to discharge without change in mental status. patient is encouraged to continue with haldol for treatment of his schizophrenia until follow up can be arranged with his outpatient psychiatrist. . # severe malnutrition: nutirition was consulted during his stay to evaluate for adequate caloric intake in the setting of poor wound healing, recurrent infections, and severe malnutrition with an albumin of 2.6. supplementations were started tid and patient was repeatedly encouraged to increase oral intake. psychiatry was consulted for concern of worsening depression contributing to poor oral intake but on their exam did not feel patient was depressed. despite initial calorie counts at 50% of goal, decision was made by the medical team to avoid tf or tpn in this patient as he has a function gut and the ability to eat. please continue heart healthy diet with tid supplements for goal calorie intake of 1800 kcal/day. please assist patient with meals to ensure adequate intake. . # persistent loose stools: c. diff neg x3. likely antibiotic associated. have been holding bowel regimen. could consider stsarting loperamide if symptoms persist and become troublesome. patient with fecal incontience at baseline. . # atrial fibrillation: recently diagnosed during last hospitalization with one episode without hemodynamic instability. currently controlled on home regimen of digoxin, metoprolol, and aspirin in sinus rhythm. aspirin was originally held on admission but resumed when spinal drains were removed as per ortho spine recs. . # diabetes mellitus type ii, complicated by hypoglycemia: well controlled, with last hga1c of 5.0. during his stay, he developed early am hypoglycemic episodes. these have been avoided with initiation of glargine, 10 units qam, 2 units qpm. patient has also been continued on qid insulin sliding scale. he is likely to benefit from uptitration of glargine as po intake is maintained. . # hyperlipidemia: no issues. continue home regimen of lipitor. his fenofibrate was discontinued in the setting of persistent looss stools. . # asthma: no active issues. he has been continued on home regimen of fluticasone and albuterol/atrovent inhalers. . # hypothyroidism: no active issues. he has been continued on levothyroxine. last tsh 5.5 on admission. should be rechecked in 6 weeks. . # schizophrenia: hallucinations resolved, believed to be at baseline now. discontinued home regimen of lexapro, abilify in setting of delirium. psychiatry following as above. continue 1mg haldol. no evidence of qtc prolongation during his stay. recommend outpatient psychiatry follow up. . # ppx: patient with ivc filter ( spinal stabilization surgery) during previous admission. patient continued on heparin sq after spinal drains removed. he was provided with an air bed with daily monitoring for ulcers. his bowel regimen has been held secondary to loose stools. . # access: picc . # code: full code . # disp: patient discharged to rehab for continued care. . #comm: with son: (for consents) medications on admission: 1. vancomycin 1000 mg iv q 24h 2. cefepime 2 g iv q12h 3. morphine sulfate 2-4 mg iv q4h:prn breakthrough pain 4. falgyl 500mg po tid 5. ondansetron 4 mg iv q8h:prn 7. oxycodone 5 mg tablet sig: two (2) tablet po q3h as needed. 8. docusate sodium 100 mg capsule po bid 9. senna 8.6 mg po bid 10. bisacodyl 5 mg po daily as needed. 11. zolpidem 5 mg po hs 12. fenofibrate micronized 145 mg po daily 13. atorvastatin 40 mg po daily 14. escitalopram 30 mg po daily 15. aripiprazole 40 mg po daily 16. alprazolam 0.25 mg 1-2 tablets po bid as needed. 17. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h as needed. 18. ipratropium bromide 17 mcg/actuation two puff inhalation qid 19. metoprolol tartrate 25 mg po bid 20. levothyroxine 150 mcg po daily 21. ferrous sulfate 325 mg (one daily). 22. aspirin 325 mg po once a day. 23. insulin glargine 20 units subcutaneous once a day. 24. insulin regular human 300 unit/3 ml insulin 25. digoxin 200 mcg po once a day. 26. heparin (porcine) 5,000 unit/ml tid discharge medications: 1. outpatient lab work please draw cbc, creatinine, bun, ast, alt, ap, t.bili, crp, esr every week x 6 weeks. please fax results to attn: 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. 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. 6. sodium chloride 0.9% flush 3 ml iv prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 7. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 8. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) inhalation inhalation every six (6) hours as needed. 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 11. lantus 100 unit/ml cartridge sig: 10 units qam, 2 units qhs units subcutaneous twice a day: please administer 10units qam and 2 units qhs. 12. insulin regular human 100 unit/ml cartridge sig: one (1) unit injection four times a day: please administer regular sliding scale qachs as per attached sheet. unit . cefepime 2 gram recon soln sig: one (1) recon soln injection q12h (every 12 hours) for 8 weeks: day 1 = . 14. haloperidol 1 mg tablet sig: one (1) tablet po bid (2 times a day). 15. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 16. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 17. vitamin d 400 unit tablet sig: four (4) tablet po once a day. 18. aspirin 325 mg tablet sig: one (1) tablet po once a day. 19. tylenol 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 20. levothyroxine 150 mcg tablet sig: one (1) tablet po once a day. 21. unasyn 3 gram recon soln sig: one (1) intravenous every four (4) hours for 8 weeks: day 1 = . discharge disposition: extended care facility: medical center - discharge diagnosis: primary: - acinetobacter / enterobacter wound infection - enterobacter bacteremia - pathologic burst fracture, t12, secondary to osteomyelitis diskitis. failure of hardware s/p removal of hardware, segmental instrumentation, fusion arthrodesis, scar revision. - toxic-metabolic encephalopathy / delirium - anemia of chronic disease - malnutrition - severe secondary: - diabetes mellitus type ii - hyperlipidemia - asthma - schizophrenia - hypothyroidism - paroxysmal atrial fibrillation - ivc filter - mssa epidural and thoracic abscesses, c4-5 discitis and osteomyelitis, cord compression and empyema/hydropneumothrorax. s/p resection of abscesses, laminectomy (t8-t12), vats decortication of right lung. - paraplegia secondary to recurrent abscess and cord compression. s/p decompression of abscesses, t9-t10 vertebral corpectomies and t8-t10 thoracic fusion with mesh cage and rod placement was performed. - to infection posterior incision c/b enterobacter cloacae bacteremia and septicemia discharge condition: hemodynamically stable. pain well-controlled on tylenol. mental status at baseline. discharge instructions: you have been admitted for an increased white blood cell count discovered in the infectious disease clinic. though you did not have a fever, you were worked up for infection and found to have bacteria in your blood. you were started on iv meropenem and vancomycin. you were taken to the operating room for incision and drainage with washout of your epidural abscess. the bacteria in your blood was identified as enterobacter, while the bacteria in your wound was identified as acinetobacter. you were started on iv antibiotics to treat these infections. you are to continue with iv cefepime and unasyn to complete a 8-week course from start date . you will have your blood counts monitored weekly and faxed to the infectious disease doctors to closely monitor your improvement and for any drug toxicities. . during your stay, you developed worsening confusion. no evidence of worsening infection or seizure was found. you were evaluated by psychiatry and they recommended decreasing your psychiatric medications to off and starting haldol two times daily to treat your confusion. please follow up with dr. to continue titration of your medications by calling . . during your stay, you were evaluated by the nutrition staff because of your severe malnutrition. the initiated daily supplementation with each meal and the intake of atleast 1800 kcals per day. to encourage you to intake sufficient calories, you were assisted by an aid with each meal. if you continue to be unable to appropriately consume enough calories, alternative sources of nutrition will be considered. . please continue daily dressing changes and wearing the tlso brace when you are out of bed. please avoid direct lying on your surgical incision to promote wound healing. you will have follow up with dr. as scheduled. . if you develop any fever, chest pain, shortness of breath, numbness, tingling, weakness or any other general worsening of condition, please call your pcp or come directly to the ed. followup instructions: you should see your orthopaedic surgeon dr. during the first week in . please call to schedule an appointment. you will have your wound examined and sutures removed at this visit. . you have an appointment with dr. in the division of infectious diseases on at 8:30 a.m. please call if you need to reschedule. . you have an appointment with dr. in the division of cardiology on at 10:40 am. if you are unable to keep your appointment, please call to reschedule. . you should follow-up with your psychiatrist dr. after you are discharged from rehab for ongoing management of your psychiatric medications. please call to schedule an appointment. . please follow-up with your primary care physician . after you are discharged from rehab. procedure: venous catheterization, not elsewhere classified reconstruction of eyelid with hair follicle graft other local excision or destruction of lesion or tissue of skin and subcutaneous tissue other exploration and decompression of spinal canal removal of implanted devices from bone, other bones biopsy of bone, other bones fusion or refusion of 2-3 vertebrae refusion of dorsal and dorsolumbar spine, posterior column, posterior technique diagnoses: other postoperative infection toxic encephalopathy unspecified acquired hypothyroidism atrial fibrillation sepsis other and unspecified hyperlipidemia diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin retention of urine, unspecified other septicemia due to gram-negative organisms chronic obstructive asthma, unspecified intraspinal abscess acute osteomyelitis, other specified sites drug-induced delirium paraplegia other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms nutritional marasmus pathologic fracture of vertebrae infection and inflammatory reaction due to other internal orthopedic device, implant, and graft bipolar i disorder, most recent episode (or current) depressed, unspecified other mechanical complication of other internal orthopedic device, implant, and graft penicillins causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to