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: sulfamethoxazole/trimethoprim / aspirin attending: chief complaint: transfer to for peg placement major surgical or invasive procedure: placement of left subclavian central line (removed), and right internal jugular central line (removed) right sided thoracentesis for pleural effusions history of present illness: 61 year-old male with longstanding dm type 1 with triopathy, status post crt (baseline creat 2.9-3.0 in ), recurrent utis with mdr organisms, history of mrsa sepsis/osteo, initially transferred on from for peg placement. * he was originally admitted to on with mental status changes. his w/u was remarkable for vre uti (only 1000 colonies) and a lll pneumonia. he was initially started on cefepime, changed to imipenem and flagyl. a repeat urine culture grew burkholderia cepacia sensitive to zosyn, and zosyn therapy was initiated on . blood cx negative. a follow-up cxr showed resolution of his lll pneumonia. a tagged wbc scan was also performed and negative for infection. he remained disoriented despite treatment of his infection, and he was felt to be continually scratching his left biceps and having facial twitching. neurology was consulted. head ct showed mild atrophy but was otherwise negative. mri showed marked atrophy, as well as subtle changes in the posterior limb of the internal capsule that could possibly represent small subacute punctate infarcts. eeg was requested, but deferred "scheduling difficulties". per neurology, mr. was loaded with dilantin for possible seizure activity, with some subsequent improvement in his mental status. * still at the osh, his hct on admission was noted to be 25, and he was transfused 2 units of prbcs. he failed a bedside swallow evaluation, and a barium swallow showed evidence of penetration and aspiration. an ngt was placed. the patient reportedly did not want a peg tube, but was deemed incompetent to make decisions by psychiatry. while in the hospital, he was begun on risperdal and celexa was increased. * on the day of transfer (), his lab work was remarkable for a hco3 drop 20-->15, with development of an anion gap acidosis. he was started on ivf with dextrose, and given 1 amp of sodium bicarbonate. on arrival to , he was hemodynamically stable. however, his initial lab work was remarkable for an anion gap of 22, with hco3 of 9, glucose of 362. abg done 7.23/22/50 (?arterial). u/a positive for ketones. of note, standing insulin had been held at outside hospital. he was given insulin sc x few doses, then started on insulin drip on the floor on , along with ivf, with eventual closure of his gap. coincident with the metabolic derangements, however, he was noted to have declining mental status (responsive only to pain at time of transfer), and he was transferred to the micu for further care. * in the micu, he was continued on the insulin drip overnight, discontinued on at 1000 after overlap with nph. ag closed. consulted, with recommendation to start lantus. regarding his mental status, neurology was consulted. lp was performed with op 9, wbc 4, rbc 0, tp 93, gluc 145, gram stain negative, cryptococcal antigen negative, cultures pending. he was loaded with dilantin on at night pending eeg on . preliminary report negative for seizure activity. per neurology, dilantin was tapered off. past medical history: 1. dm type 1 with triopathy 2. status post cadaveric renal transplant in 3. chronic renal insufficiency with baseline creatinine 2.9-3.0 in 4. peripheral neuropathy 6. hypertension 7. cad, lvef >55% in 8. gerd 9. hypercholesterolemia 10. history of mrsa osteomyelitis/sepsis 11. history of recurrent utis with mdr organisms * other past surgical history: status post right thr status post left bka status post open chlecystectomy social history: widowed, ex-meat cutter, no tob, no etoh, no ivdu family history: mother with dm and pm and father with pm physical exam: vitals: tm 99.2, tc 98.9, hr 60s-70s, bp 120-170/50-60s, rr high teens to low 20s, sat 98-100% on ra. i/o: + 450 last 24 hours, then + 1700 cc today gen: caucasian male, in nad. answers questions, recognizes his name, not oriented to place or time. makes eye contact. : pupils sluggish, reactive. dry mm. neck: no cervical ln. resp: limited examination, clear anteriorly. cvs: rrr. normal s1, s2. gi: bs +. soft, non-tender. ext: 2+ pedal edema rle. left bka. neuro: moves all 4 extremities. pertinent results: micro: blood culture x2 negative csf spinal fluid gs negative, cultures negative csf cryptococcal antigen negative blood culture x 4 bottles negative * labs: trop 0.14 trop 0.16 ck-mb 2 trop 0.16 trop 0.20 relevant imaging studies: osh: cxr with lll pneumonia, resolved on cxr tagged wbc scan negative ct head: atrophy, no focal disease mri head: marked atrophic changes, possible subacute punctate infarcts. * : cxr: probable bibasilar pneumonia renal transplant u/s: normal ct head: no intracranial hemorrhage. no major vascular territorial infarction. eeg: bursts of generalized slowing consistent with encephalopathy. . mri with gadolinium, stroke protocol: mild-to-moderate brain atrophy and a chronic lacune in the posterior limb of the left internal capsule unchanged from the previous mri of . there are no mri signs of posterior encephalopathy seen. no mass effect or hydrocephalus noted. no acute infarcts are seen. egd: gastric antrum, mucosal biopsy - negative for h. pylori ct sinuses: no air-fluid levels to suggest acute sinusitis. mild mucosal thickening in the paranasal sinuses, as described. v/q scan: indeterminate lung scan. there are bilateral areas of decreased perfusion within the lung bases, asymmetrically with a larger defect on the right. although the pattern of this perfusion could be explained by bilateral pleural effusion, in the face of these abnormalities, it is difficult to exclude a pulmonary embolism. ct chest without contrast: 1. large bilateral pleural effusions with associated compressive atelectasis that are little changed when compared to . otherwise, clear lungs. 2. slightly dilated esophagus 3. dilatation of the extrahepatic biliary system with a probable calcified filling defect in the distal common duct. clinical correlation is advised. brief hospital course: assessment and plan: 61 yo male with longstanding dm type 1 with triopathy, s/p crt in on immunosuppression, transferred from osh with uti, change in mental status, in dka. dka resolved. also being anticoagulated for left dvt, likely pe. moderate to large pleural effusions bilaterally s/p right thoracentesis. pt has had chronic complaints of chest pain x >1 month, with negative work-ups, pain likely due to combination of costochondritis plus possible pe. pt also with ugib, esophagitis, duodenitis, duodenal ulcer not actively bleeding, and hct stable on anticoagulation. treated for uti with zosyn, however, pt found to have new uti during admission with fever, which was treated w/ meropenem. * 1) pe/dvt/chest pain: - pt complaining of chest pain which he reports to have had for greater than 1 month, pleuritic or with exertion. ekgs showed no changes from baseline, no ischemic changes. he had elevated cardiac enzymes, which were felt to be secondary to his poor renal clearance in addition to possible demand ischemia as they were drawn during a period of anemia/ugib. he had lower extremity dopplers which were positive for dvt in left superficial femoral vein, extending to beginning of popliteal. a v/q scan was performed as the pt was unable to have a cta due to his renal status; however, the study was suboptimal, unable to perform ventilation portion of study - on perfusion scan, unable to visualize bases bilateral pleural effusions, therefore unable to r/o pe's. the pt was started on heparin; coumadin was started at 3 mg, then increased to 5 mg to reach therapeutic inr of 1.7. - the patient also had bilateral pleural effusions which were present on chest ct's from a year ago. on , an ultrasound guided thoracentesis of right pleural effusion was performed, 1.2l was removed. pleural fluid showed no pmn's or organisms, ldh ratio indicative of transudative process, pleural cx's negative bacteria, fungus, afb smear, and cytology negative for malignancy. - pt also had reproducible cp on palpation over sternum, possible costochondritis. rib xray negative for fracture. * 2) id: the patient completed 2 week course of zosyn for uti as described above on . however, the pt subsequently became febrile accompanied by change in mental status, increased wbc - now has been afebrile with much improved mental status and decreasing wbc. broad spectrum abx started , with vancomycin renally dosed (discontinued) and zosyn; however, urine cx results + for non-fermenter not pseudomonas, intermediate sensitivity to zosyn, sensitive to meropenem. ruled out for pna, sinusitis, c. diff, line infection. zosyn was therefore discontinued, and pt was treated with meropenem 500 iv x7 days, completed . the patient also had yeast on ua/ucx, and was started on fluconazole x ~10 day course. the pt was subsequently afebrile with normal wbc, stable mental status. . id work-up: - central line d/c'd , placed ; new rij placed . - c.diff negative - diarrhea, likely from gi blood. - blood cultures 11/22, 23 negative - kub: no free air or obstruction - cxr: small bilateral pleural effusions - ct sinuses: no acute sinusitis; some paranasal sinus thickening - catheter tip: no significant growth - , 30 blood cultures no growth * 3) gi: upper gi bleed coffee ground emesis , and again on , requiring transfusions of prbc's, total 4 units. egd was performed , and showed esophagitis, duodenitis, duodenal ulcer, no active bleeding. an ngt was placed for gastric decompression, d/c'd . hct stable on anticoagulation. egd biopsy negative for h. pylori, protonix po bid, sucralfate qid. - the pt also developed fleeting ruq pain. incidental finding on chest ct , showed dilatation of the extrahepatic biliary system with a calcific density in the expected location of the distal common duct. ruq resolved, lft's and bilirubin normal except for increased alk phos ( 208, 439, 452). the pt may have some common bile duct stone/obstruction, given ct finding, however, he has declined ercp despite discussing possibility for progression to infection. * 4) dm type 1/dka: - dka resolved. basal insulin had been held at osh (transferred only on riss). pt's blood sugar was quite labile, fluctuating depending upon po status, infectious states, and had period of both low fsg's to 30's necessitating d50, as well as hyperglycemia to 477. he had fsg's checked qachs, and at 3am. his current regimen includes glargine 18 u at noon daily, as well as sliding scale included. * 5) delta ms: - the pt had an extensive work-up for initial changes in mental status, including an eeg which showed no epileptiform activity, lp with elevated protein and glucose, no evidence of infection, normal op, negative cultures, negative for cmv, virus, vzv. mri showed mild-to-moderate brain atrophy and a chronic lacune in the posterior limb of the left internal capsule unchanged from the previous mri of , no mri signs of posterior encephalopathy seen, no mass effect or hydrocephalus noted, no acute infarcts. - the pt's mental status changes were attributed to combination of acute infection as well as hyperglycemia/dka. he demonstrates mental status deterioration when febrile or infected, and when blood sugars are either elevated or low. the pt now at his new baseline, is awake and alert, speaking fluently, and cooperative with exam. * 6) s/p renal transplant: - the pt's immunosuppresion regimen was adjusted several times during course of admission. regimen on discharge includes: ** tacrolimus 1.5 mg ** sirolimus 2 mg mwf, 1 mg tthsasun ** prednisone 4 mg qd - the pt's cr slightly increased during admission to peak of 2.9. this may have been in the context of taking sublingual tacrolimus while npo, which per pharmacy causes greater bioavailability of drug and possible renal effect. cr subsequently decreased to 2.6. medications were adjusted for crcl <30. * 7) heme/anemia: upper gi bleed, plus anemia of chronic disease. hct decreased acutely in context of coffee ground emesis, with hct down to low of 20; received 1 unit prbc's after initial gib, and an additional 3 units . pt was on epogen, decreased steadily from 8000 units 3x/week to units 3x/week. hct remained stable for the last several weeks of admission, even while therapeutic on anticoagulation. last hct prior to discharge was 36.2 * 8) fen: - pt was initially npo while he had initial mental status changes. however, after treatment for dka/hyperglycemia and infections, he passed a bedside speech and swallow with no aspiration, was allowed to commence po diet. * 9) cv: patient with htn, cad. -pt had elevated blood pressures during last few weeks of admission. hydralazine had been d/c'd and amlodipine decreased to 5 qd in context of gi bleed and anemia. however, amlodipine was increased back to 10 as pt subsequently hypertensive. lasix 20 mg qd was also started secondary to htn * 10) derm: the pt was seen by dermatology for a scaling plaque, possible squamous cell ca on left temple. will need to schedule excisional biopsy as outpatient in derm clinic . * 11) psych: pt seen by psych consult for possible depression, no active suicidal ideation, but expressed desire to not pursue major interventions to prolong life; he is not denying any specific procedures at this time. per psychiatry, pt does not appear to be suicidal, and his wishes to limit invasive procedures is reasonable. celexa increased to 30 mg qd. * 12) pt/ot: evaluated by pt/ot during admission, rehab recommmended for ambulation and mobilization given left bka, deconditioning. medications on admission: meds on admission to osh (presumed) feosol 325 mg daily, colace 100 mg daily, senokot 1 tab qhs, flomax 0.4 mg qhd, reglan 10 mg po bid, lopressor 75 mg twice daily, norvasc 10 mg daily, plavix 75 mg daily, nexium 40 mg daily, celexa 10 mg daily, lasix 20 mg iv daily, hydralazine 10 mg po q6hours, cefepime 1 gm iv daily, prednisone 5 mg daily, mvi daily, tacrolimus 0.5 mg , heparin 5000 units sc bid humulin n 10 units qam, 5 units qhs * meds at time of transfer: rapamune 3 tabs 1 mg po daily protonix 40 mg iv daily tacrolimmus 0.5 mg po bid dilantin 300 mg po qhs norvasc 10 mg po qd zosyn 2.25 gm iv q6 hours (day 6 on transfer) lopressor 125 mg po bid celexa 20 mg daily risperidone 0.5 mg po bid riss * current meds in micu: metoprolol 75 mg po bid pantoprazole 40 mg iv q24h amlodipine 10 mg po daily citalopram hydrobromide 20 mg po daily phenytoin 100 mg iv q12h for 2 days, then 100 mg iv daily for 2 days daptomycin 300 mg iv q48h day 2 piperacillin-tazobactam na 2.25 gm iv q6h docusate sodium (liquid) 100 mg po bid epoetin alfa 4000 unit sc qmowefr start: hs senna 2 tab po bid:prn folic acid 1 mg iv daily sirolimus 3 mg po daily heparin 5000 unit sc tid tacrolimus 1 mg po bid renal transplant thiamine hcl 100 mg iv daily insulin sc glargine 10 units qhs (to receive first dose tonight) * discharge medications: 1. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. therapeutic multivitamin liquid sig: one (1) cap po daily (daily). 5. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 6. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for 1 weeks. 7. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). 8. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily): hold for sbp <110. 10. codeine sulfate 30 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed: please give 1/2 hr prior to pt. 11. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 12. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 14. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day) for 1 weeks: perianal area. 15. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 16. sirolimus 1 mg tablet sig: two (2) tablet po qmowefr (monday -wednesday-friday). 17. sirolimus 1 mg tablet sig: one (1) tablet po qtuthsa (,tu,th,sa). 18. tacrolimus 0.5 mg capsule sig: three (3) capsule po bid (2 times a day). 19. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day) as needed. 20. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 weeks. 21. insulin glargine 100 unit/ml solution sig: one (1) subcutaneous once a day: 18 units glargine at noon daily. 22. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 23. loperamide 2 mg capsule sig: one (1) capsule po tid (3 times a day) as needed. 24. outpatient lab work please check tacrolimus and sirolimus levels q3 days, please send results to transplant center at or . 25. outpatient lab work please check coags/inr twice weekly, and adjust coumadin level accordingly. 26. epoetin alfa 2,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday): u mwf. discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: type i diabetes, cadaveric renal transplant, left dvt/?pe on anticoagulation, pleural effusions, upper gi bleeds (resolved) from esophagitis/duodenitis/duodenal ulcer, uti and yeast in urine discharge condition: stable discharge instructions: please continue taking your medications as written. please call your physician if you have any worsened chest pain, shortness of breath, palpitations, cough, fever, urinary symptoms, vomiting blood/"coffee ground" material, lightheadedness/dizziness, confusion, other worrisome symptoms followup instructions: please call dr. for follow-up appointment once discharged from wedgemere . you will need your blood levels of tacrolimus and rapamycin drawn every 3rd day, and results sent to tranplant center - please call for an appointment to be seen in clinic after discharge from wedgemere, for biopsy of lesion on left temple, md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung enteral infusion of concentrated nutritional substances thoracentesis insertion of other (naso-)gastric tube esophagogastroduodenoscopy [egd] with closed biopsy diagnoses: pneumonia, organism unspecified unspecified pleural effusion urinary tract infection, site not specified unspecified essential hypertension diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled unspecified disorder of skin and subcutaneous tissue hematemesis hyperosmolality and/or hypernatremia complications of transplanted kidney below knee amputation status unspecified infectious and parasitic diseases hip joint replacement 

Answer: The patient is high likely exposed to