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: cipro / doxycycline / paxil / quinine / compazine / levaquin / lithium / cefepime attending: chief complaint: abdominal pain, nausea, vomiting major surgical or invasive procedure: exploratory laparotomy with lysis of adhesions, bowel decompression and sb enterotomy egd history of present illness: the patient is a 55 yo female w/ hx multiple small bowel obstructions, likely secondary to previous intraabdominal surgery who was admitted to on with concerns for small bowel obstruction, given her symptoms of nausea, vomiting, and abdominal pain. (per surgery admission note) past medical history: # hepatic sarcoidosis and regenerative hyperplasia - s/p tips placed d/t gi bleeding from varices and portal gastropathy - tips re-do with angioplasty and portal vein embolectomy - severe portal hypertensive gastropathy - grade ii varices - grade 3 esophagitis # multiple sbos, most recent # idiopathic cardiomyopathy: -echo demonstrating an ef of 15-20% (no report, ?osh) and a p-mibi that confirmed an ef of 23% with no ischemic changes--> improving to ef 40-45%, mild-to-moderate global left ventricular hypokinesis -cardiac cath : no angiographically apparent flow-limiting lesions, mild mitral regurgitation, and severe systolic ventricular dysfunction with a left ventricular ejection fraction of 20%. -right heart cath: : normal right sided filling pressures. mild pulmonary artery hypertension. preserved cardiac index. # copd, followed by , pfts wnl # hx of sah s/p coiling, 2 new aneurysms seen on angio # colonic avm and diverticulum # evidence of cva/tia # hypothyroidism # anemia # s/p hysterectomy # s/p cholecystecomy # s/p appendectomy # reflex sympathetic dystrophy s/p fall, on disability, now resolved # raynauds social history: married, lives in , has 2 sons and 5 grandchildren, 36 pack-year smoking hx quit 2.5 years ago, does not drink etoh and denies former abuse, no h/o illicits or ivdu, does not work disability for rsd. family history: mi, physical exam: physical exam on transfer from micu to - wards. initial pe not available vs: tc 98, tm98.4, hr 98 (90-100s), 130/64 (100-140/50/80), 19 heent: eeg leads in place, sclerae anicteric, perrl, op clear neck: supple, no lymphadenopathy cor: rrr, no murmurs appreciated pulm: clear anteriorly abd: midline laparotomy scar wellhealed, voluntary guarding with palpation of abdomen diffusely, normoactive bowel sounds, no rebound extrem: no peripheral edema neuro: responds to voice, oriented to self & place, states "i'm worried about him . he's always been here for me," after being asked if her husband has been in to see her today. no twitching. difficulty engaging pt in exam. moves all ext's spontaneously pertinent results: admission labs wbc-6.6# rbc-3.69* hgb-11.2* hct-32.9* mcv-89 mch-30.3 mchc-34.0 rdw-16.5* plt ct-64* neuts-89.5* lymphs-5.1* monos-3.4 eos-1.6 baso-0.4 pt-12.9 ptt-30.8 inr(pt)-1.1 glucose-95 urean-25* creat-1.1 na-140 k-4.9 cl-105 hco3-24 angap-16 alt-27 ast-33 alkphos-197* totbili-0.9 mg-1.6 caltibc-178* ferritn-418* trf-137* ammonia-60* urine color-straw appear-clear sp -1.006 urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg miscellaneous lab data 02:37am blood wbc-6.3 rbc-3.39* hgb-9.7* hct-30.1* mcv-89 mch-28.6 mchc-32.3 rdw-15.2 plt ct-74* 10:12am blood wbc-7.0 rbc-3.09* hgb-9.1* hct-26.7* mcv-86 mch-29.4 mchc-34.1 rdw-16.8* plt ct-106* 12:20pm blood wbc-7.2 rbc-3.31* hgb-10.2* hct-28.7* mcv-87 mch-30.9 mchc-35.6* rdw-16.5* plt ct-60* 08:57pm blood fibrino-598* 04:22am blood glucose-97 urean-41* creat-1.0 na-137 k-4.3 cl-108 hco3-23 angap-10 05:30am blood glucose-214* urean-57* creat-1.8* na-148* k-4.1 cl-116* hco3-21* angap-15 10:45am blood glucose-295* urean-63* creat-1.4* na-150* k-4.3 cl-120* hco3-19* angap-15 06:58am blood glucose-125* urean-91* creat-2.1* na-136 k-4.6 cl-109* hco3-14* angap-18 06:30am blood glucose-119* urean-97* creat-2.6* na-137 k-4.9 cl-111* hco3-11* angap-20 02:19pm blood glucose-134* urean-93* creat-3.1* na-145 k-4.0 cl-118* hco3-14* angap-17 05:00am blood glucose-86 urean-57* creat-2.5* na-138 k-3.9 cl-108 hco3-20* angap-14 05:37am blood glucose-82 urean-49* creat-2.2* na-139 k-3.5 cl-109* hco3-20* angap-14 06:58am blood alt-13 ast-17 ld(ldh)-173 ck(cpk)-14* alkphos-177* totbili-0.4 05:20am blood triglyc-206* hdl-51 chol/hd-2.8 ldlcalc-51 04:48pm blood ammonia-6* 11:06am blood ammonia-49* 01:47am blood tsh-0.37 05:43pm blood phenyto-18.0 02:19pm blood phenyto-21.2* 05:03am blood phenyto-12.0 discharge labs 05:03am blood wbc-3.7* rbc-3.29* hgb-9.9* hct-28.6* mcv-87 mch-30.1 mchc-34.6 rdw-16.0* plt ct-90* 05:03am blood plt ct-90* 05:03am blood glucose-92 urean-44* creat-2.0* na-140 k-3.9 cl-111* hco3-20* angap-13 05:03am blood alt-12 ast-18 ld(ldh)-218 alkphos-232* totbili-0.4 05:03am blood albumin-3.4 calcium-8.1* phos-3.3 mg-2.2 05:03am blood phenyto-12.0 . imaging: abdominal us: no significant abdominal ascites and no tapable fluid collection. cirrhotic liver with portal htn including splenomegaly. probable sbo, incompletely visualized on examination. ct a/p: sbo with transition point in rlq. no bowel wall thickening or pneumatosis. also c/w cirrhosis and portal htn. tips shunt occluded. ct a/p: same transition pt in rlq pelvis with fecalization of sb proximal to this pt, ? anther transition pt at proximal sb but contrast passes thru; no pneumatosis egd: 3 nonbleeding grade 2 varices in distal esophagus; portal hypertension gastritis w small blood clot in stomach; no active bleeding. kub: persistent small-bowel obstruction or postop ileus ct abd: persistent dilation of multiple loops of small bowel with wall thickening and mesenteric edema without a definitive transition point. although there is a relative point in the terminal ileum, these findings suggest the possibility of mixed mechanical and functional obstruction; cirrhotic liver with tips and portal hypertension, such as splenomegaly; diverticulosis without evidence of diverticulitis. abd u/s and duplex: scant ascites, patent vasculature, no biliary dilatation ct abd: there is increased ascites compared to prior study. there is no focal fluid collection to suggest abscess formation. there is diffuse anasarca and mesenteric edema. small bowel is mildly dilated with mild bowel wall thickening, decreased since prior study. there is no pneumatosis or free air. . micro: abd jp: klebsiella oxytoca and abd jp: klebsiella oxytoca : ascites fluid gram stain with gram negative rods bld cx pending 06:15am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-sm 06:15am urine rbc-5* wbc-12* bacteri-few yeast-none epi-1 transe-<1 10:40am urine eos-negative 03:32pm urine hours-random na-88 k-30 cl-93 10:40am urine hours-random creat-39 na-48 03:45pm cerebrospinal fluid (csf) wbc-0 rbc-93* polys-20 lymphs-60 monos- wbc-0 rbc-* polys-33 bands-7 lymphs-33 monos-27 totprot-32 glucose-53 ld(ldh)-34 angiotensin 1 converting enzyme-test herpes simplex virus pcr-test name ascites studies 07:44pm ascites wbc-7400* rbc-250* polys-88* lymphs-4* monos-0 mesothe-3* macroph-5* 06:17pm ascites wbc-5250* rbc-200* polys-93* lymphs-4* monos-3* 03:03pm ascites wbc-1025* rbc-* polys-66* lymphs-13* monos-0 eos-1* macroph-20* 10:00am ascites wbc-125* rbc-5175* polys-38* lymphs-46* monos-0 eos-1* mesothe-2* macroph-13* 06:17pm ascites totpro-0.8 glucose-157 amylase-36 totbili-0.2 albumin-<1.0 03:03pm ascites totpro-1.8 glucose-118 ld(ldh)-78 amylase-25 albumin-1.1 brief hospital course: hospital course as summarized by surgical and medical services mrs. is a 55 yo female with with history of elsd from hepatic sarcoid who initially presented on w/ small bowel obstruction and had hospital course complicated by arf, status epilepticus, secondary bacterial peritonitis, and hepatic encephalopathy. brief hospital course by problem small bowel obstruction the patient was admitted to with nausea, abdominal pain, and diarrhea. given her history of hepatic sarcoidsis, the patient underwent ct of abd/pelvis revealing a transition point in rlq pelvis with fecalization of sb proximal to this pt. of note, prior ct on had revealed cirrhosis and portal htn with tips shunt occluded. the patient was thus taken to the or on where she underwent exploratory laparotomy with enterotomy and lysis of adhesions. intraoperatively she was found to have some adhesions with dilated loops of bowel but no transition point; the small bowel was dilated to the extent that an enterotomy was required in order to decompress the bowel and close the abdomen. she also had a cvl placed in the or. she was kept intubated overnight and brought to the icu. she was weaned to extubated in the am. she received perioperative antibiotics and stress dose steroids postoperatively. esophageal varices/anemia/portal gastropathy she also had an egd on that revealed 3 nonbleeding grade 2 varices in distal esophagus and portal hypertension gastritis w small blood clot in stomach; no active bleeding. she had a relatively stable anemia that trended down around that was thought to be morst likely secondary to slow ooze from portal gastropathy. she was transfused 2 units prbc , 1 unit with subsequent stabilization of hct. varices were banded on day of discharge and she was started on sucralfate for 10 days. postoperative ileus on she was transferred to the floor, her ngt was discontinued, and she was started on sips, which she tolerated well. on she was noticed to be increasingly tender without bowel movements; kub revealed persistent dilated small-bowel loops with multiple air-fluid levels concerning for persistent small-bowel obstruction or post-operative ileus. her ngt was replaced. she was started empirically on unasyn. acute renal failure while on surgical service, the patient was also noted to have an increase in her creatinine from 1.3 to 2.2; this was thought secondary to large fluid losses from her jp drain in her abdomen; she was started on replacements 1/2 cc/cc with improvement in her creatinine to 1.2 on . she had a picc placed on and was started on tpn. she again developed a rise in her creatinine on . she was given albumin 62.5g on and bicarb and blood on for volume rescusitation. urine microscopy showed granular and hyaline cast. urine lytes were not consistent with pre-renal but renal felt this was a pre-renal/evolving atn picture. she has a mixed non-gap and gap acidosis. the gap is likely from the renal failure and the non-gap from her diarrhea. the bicarb has improved her acid-base status and lactulose was stopped to slow down the diarrhea. creatinine trended down prior to discharge. diuretics were held. hepatic encephalopathy on the floor the patient was noticed to be increasingly less talkative with a dull affect, thought to be consistent with past episodes of hepatic encephalopathy. she was given high dose lactulose pr with initial improvement in her mental status. secondary bacterial peritonitis the patient had been improving, and so her ngt was discontinued. unfortunately, she then developed increasing abdominal pain; on she underwent repeat ct scan of abd/pelvis that revealed persistent dilation of multiple loops of small bowel with wall thickening and mesenteric edema without a definitive transition point concerning for a mixed mechanical and functional obstruction, a cirrhotic liver with tips and portal hypertension, such as splenomegaly, and diverticulosis without evidence of diverticulitis. the jp drain fluid was sent for analysis; klebsiella oxytoca and grew out from the fluid both on and . infectious disease was consulted; the patient was started on zosyn for the klebsiella and for the . the zosyn was eventually changed to cefepime on given the sensitivities. cefepime was later changed to meropenem due to concern for precipitating seizure. her home gabapentin and amitriptyline were held given their potential muscarinic effects on peristalsis. the patient had been having low-grade fevers in the setting of steroids but no mental status changes at the time. she was thought to have infected peritoneal fluid possibly secondary to the enterotomy, though the etiology is not completely clear. serial paracenteses were performed until pt no longer had evidence of bacterial peritonitis with <250 polys in ascitic fluid. she was continued on antibiotics for two week course after jp pulled to complete . the patient's abdominal exam gradually improved, her ngt was discontinued on , and she was started on a regular diet given that she was passing gas and having bowel movements. that said, the patient continued to have low-grade fevers throughout even though she was still on steroids (tapered to her home dose from admission) and multiple antibiotics. because of her improved exam, decreased output from her jp and the thought that her fluid status could be better managed with the drain out, her jp drain was removed. she did have some tenederness on abdominal exam on , and so she underwent another ct scan that revealed increased ascites compared to prior study but no focal fluid collection to suggest abscess formation. the patient did have diffuse anasarca and mesenteric edema; the small bowel was mildly dilated with mild bowel wall thickening, decreased since prior study, and there was no pneumatosis or free air. hypernatremia the patient also became hypernatremic to a high of 154 on (she was started on free water replacements), likely intravascularly depleted given her high bun, and hyperchloremic with a low bicarbonate; the later two likely secondary to previous normal saline/tpn loads. given her stable vital signs, she was transferred to the floor on , though she still remains with altered mental status further discuused below. altered mental status on the patient was noted to be increasingly abulic, though paranoid appearing. she was transferred to the sicu. she underwent an abd u/s on that revealed scant ascites, patent vasculature, and biliary dilatation. given the results the patient did not undergo paracentesis even though this was one possible etiology for her ams. both psychiatry (who had previously been following the patient for depression) and neurology were consulted. her mental status waxed and waned with occasional episodes of increased awareness and pronouncing her name. her altered mental status was initially thought to be due to toxic metabolic encephalopathy liver disease, infection, and underlying brain disease. her eeg on was consistent with this and negative for seizure per neurology although there was a questionable focus in the frontal lobe. lp and mri/a were performed and were both negative on . ng tube was pulled out on and put back in and patient was treated with lactulose with stool outputs of a liter per day. patient had paracentesis with reduction in white cells but persistent bacterial peritonitis and gram negative rods on gram stain. on , per id, metronidazole was added to cover anerobes. patient had been on cefepime for klebsiella and for since her initial tap. she completed 2 week course (after jp pulled) with change of antibiotics to meropenem (then ertapenem at discharge for once daily dosing) and caspo. status epilepticus on the morning of she was noted to be "twitching". her glucose and electrolytes were wnl. neurology was contact and initially did not think this was seizure activity but eeg was ordered to r/o myoclonic seizure. eeg demonstrated status epilepticus. she was given 2 mg iv ativan and this resolved. she was loaded with fosphenytoin and continued on fosphenytoin with daily monitoring of levels. it was unclear what precipitaed seizures but may have been form underlying brain disease (h/o cva), hepatic encephalopathy, or med effect. flagyl was discontinued and cefeoime changed to . she was transferred to micu fo closer monitoring. ekg and cxr were wnl during this episode. when her mental status remained altered after being on therapeutic dilantin, she was started on keppra in addition to dilantin. mental status subsequently continued to improve and she became awake, oriented and conversant. she was started on a regular diet and started working with physical therapy and was discharged to home with services. hypothyroidism continued on levothroxine. tsh wnl. code full medications on admission: albuterol 90 mcg 1 puff inh q4-6h prn, amitriptyline 50 qhs, cyanocobalamin 1000 mcg/ml qmonth, folic acid 1', lasix 20', gabapentin 300'', hydroxyzine 25''', lactulose 10g/15ml soln 2 teaspoons daily, levothyroxine 88', omeprazole 80'', prednisone 10', aldactone 50', sucralfatre 1 qid, ursodiol 600 qam 300 qpm, ambien 10 qhs, ferrous sulfate 325'', vit b1 100' discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 2. 200 mg tablet sig: two (2) tablet po tid (3 times a day). 3. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 4. ursodiol 300 mg capsule sig: as directed capsule po twice a day: take 2 tabs in am and 1 tab at night. 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 6. 70 mg recon soln sig: 35 mg recon solns intravenous q24h (every 24 hours) for 4 doses. disp:*2 recon soln(s)* refills:*0* 7. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): titrate to 4 bms per day. 8. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. cyanocobalamin 1,000 mcg/ml solution sig: one (1) injection injection once a month. 10. folic acid 1 mg tablet sig: one (1) tablet po once a day. 11. ertapenem 1 gram recon soln sig: 0.5 grams intravenous once a day for 4 days. disp:*2 grams* refills:*0* 12. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 13. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for 2 weeks. disp:*1 bottle* refills:*0* 14. dilantin extended 100 mg capsule sig: one (1) capsule po three times a day. disp:*90 capsule(s)* refills:*2* 15. keppra 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 16. sucralfate 100 mg/ml suspension sig: one (1) gram po twice a day for 10 days: do not take within 2 hours of taking dilantin (phenytoin). disp:*200 grams* refills:*0* 17. thiamine hcl 100 mg tablet sig: one (1) tablet po once a day. 18. gabapentin 300 mg capsule sig: one (1) capsule po once a day. 19. outpatient lab work please check cbc, chem-10, lfts on friday . please have results faxed to dr. at ( 20. saline flush 0.9 % syringe sig: one (1) flush injection four times a day: 10 cc sash and prn. disp:*16 flushes* refills:*0* 21. heparin flush 10 unit/ml kit sig: one (1) flush intravenous once a day: 3 cc sash and prn. disp:*10 flushes* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis small bowel obstruction s/p lysis of adhesions acute renal failure status epilepticus secondary bacterial peritonitis secondary diagnosis hepatic sarcoidosis listed for transplant esophageal varices grade ii severe portal hypertensive gastropathy esophagitis multiple admissions for hepatic encephalopathy multiple prior sbo's (treated non-operatively) copd h/o cva/tia's hypothyroidism raynaud's syndrome cerebral aneurysms s/p coiling after sah discharge condition: hemodynamically stable, afebrile discharge instructions: you were admitted to the hospital with abdominal pain. you were found to have a small bowel obstruction which required surgery to lyse adhesions in your abdomen. you later developed an infection in your abdomen and were started on antibiotics. a repeat paracentesis on showed that this infection had resolved but you should continue to tkae antibiotics through . during your hospital course, you also developed kidney failure which may have been from one of the medications you were taking. you also were confused so you were treated with lactulose and for hepatic encephalopathy. on , you had some twitching so an eeg was obtained which showed that you were having seizures. you were treated with dilantin and keppra and your seizures stopped. we have made the following changes to your medications 1. we held your diuretics (lasix and aldactone) since you had impaired kidney function. these may be restarted as an outpatient depending on your kidney function and electrolytes. 2. we added ertapenem and , antibiotic and antifungal medication which you will take through 3. we added phenytoin and keppra for seizures 4. we added sucralfate for varices for 10 days, please make sure not to take this medication within 2 hours of dilantin. they need to be spaced at least 2 hours. 5. we decreased your gabapentin to 300 mg once daily because of your renal function. please return to the er or call your primary care doctor if you develop confusion, abdominal pain, fever, chills, chest pain, shortness of breath or any other concerning symptoms. followup instructions: please follow-up with dr. , md phone:. you have an appointment with him at 8:30 am on . you also have an appointment for endoscopy on at 8:30 provider: (st-3) gi rooms. please follow up with neurology regarding your seizures. you have an appointment with dr. and on at 2:30 pm. their office is on the of the building. please follow up with surgery in the next 1-2 weeks. you have an appointment with dr. on at 8 am. his office is at . on the . at this time, he will take out the stitches on your abdomen. please follow up with your pcp in the next few weeks as well. call dr. office when you are able. procedure: venous catheterization, not elsewhere classified spinal tap incision of lung parenteral infusion of concentrated nutritional substances other endoscopy of small intestine percutaneous abdominal drainage percutaneous abdominal drainage endoscopic excision or destruction of lesion or tissue of esophagus other lysis of peritoneal adhesions transfusion of packed cells other incision of small intestine electroencephalogram diagnoses: acidosis acute kidney failure with lesion of tubular necrosis friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site cirrhosis of liver without mention of alcohol portal hypertension unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified personal history of tobacco use sarcoidosis other complications due to other vascular device, implant, and graft grand mal status paralytic ileus other sequelae of chronic liver disease other ascites hematemesis hepatic encephalopathy hyperosmolality and/or hypernatremia esophageal varices in diseases classified elsewhere, without mention of bleeding raynaud's syndrome intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) other esophagitis hemorrhage of rectum and anus other suppurative peritonitis family history of other cardiovascular diseases reflex sympathetic dystrophy, unspecified cardiomyopathy in other diseases classified elsewhere candidiasis of unspecified site family history of other lymphatic and hematopoietic neoplasms 

Answer: The patient is high likely exposed to