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: codeine / vicodin / percocet / compazine / percodan / tigan / latex / betadine viscous gauze / protonix / surgical lubricant attending: chief complaint: "severe all over body pain" major surgical or invasive procedure: - esophagogastroduodenoscopy history of present illness: 60-year-old female with history of etoh/nash cirrhosis complicated by ascites and encephalopathy (no known varices or history of sbp) who presents with "severe all over body pain". . the patient was recently admitted for hypotension and hyponatremia where she was found to have esbl uti and treated with tobramycin/tetracycline. she was discharged to a nursing home on . at the nursing home, the patient states that she has not been taking her lactulose and has not had bowel movements. she is confused and states she has "all over body pain" although she is unable to describe it and unsure of if it is different or more severe than her baseline chronic pain. she presents to for further evaluation. . upon presentation to the ew, intial vitals were: t 98.2, hr 86, bp 130/80, rr 18, sao2 97% ra. labs show inr 1.6, hct 27 (near recent baseline), lfts okay. she is confused and has asterixis on exam. she denies rectal. cxr with question of focal infiltrate. kub with dilated loops of small bowel likely secondary to ileus (although cannot rule out obstruction). ultrasound with difficult anatomy and not enough ascites to safely do diagnostic paracentesis at bedside. recommend ultrasound guided paracentesis. she received lactulose and was admitted for hepatic encephalopathy treatment. . currently, patient confused. yelling at nurses and very slow with movement. she notes chills, nausea, right upper quadrant discomfort and diffuse pain. she is unsure if this is different than baseline. she is unsure of her last bowel movement and is unsure if she is taking lactulose. she denies or does not know about other ros. past medical history: 1. cirrhosis: thought to be secondary to etoh use and fatty liver disease 2. h/o pancreatitis 3. etoh abuse 4. cholelithiasis 5. obesity 6. hypothyroidism 7. venous insuffuciency 8. chronic lower extremity edema 9. spinal stenosis 10. reflex sympathetic dystrophy 11. hypokalemia 12. mitral regurgitation 13. neuropathy 14. bilateral hand weakness 15. osteoporosis 16. macrocytic anemia 17. thrombocytopenia 18. uterine fibroids 19. chronic renal insufficiency 20. "tummy tuck" 21. chronic pain: on narcotics social history: lives with her roomate. is a former constable and volunteer police officer. drinks 3-4 beers/day x 12 yrs. no h/o withdrawl szs. no tobacco or illicit drug use. estranged from family. no hcp, though patient believes that father or could be hcp. family history: aunt with cirrhosis. mother with alcoholism. physical exam: vs: t 98.2, bp 104/66, hr 86, rr 16, sao2 94% ra general: yelling at nurses - "no - i want to do it my own way", no apparent distress heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear neck: supple lungs: limited lung volumes, bibasilar crackles, no cough, wheezes. heart: rr, nl rate, i/vi murmur abdomen: obese, soft, diffuse tenderness no rebound or guarding, decreased bowel sounds extremities: warm, le edema 2+ skin: stasis dermatitis bilateral lower extremities, multiple ecchymotic lesions, rash right forearm neuro - awake, a&ox2 (name and hospital, wrong day, month, unsure of year) unwilling to participate in neuro examination, very upset when asked to participate, emotionally labile. + asterixis. pertinent results: labs on admission: 06:54pm comments-green top 06:54pm glucose-89 lactate-1.4 na+-131* k+-3.5 cl--97* tco2-26 06:50pm urea n-10 creat-1.0 06:50pm estgfr-using this 06:50pm alt(sgpt)-15 ast(sgot)-22 ld(ldh)-227 alk phos-61 tot bili-1.9* 06:50pm lipase-14 06:50pm calcium-9.3 phosphate-3.9# magnesium-1.5* 06:50pm wbc-5.7 rbc-2.43* hgb-9.1* hct-27.0* mcv-111* mch-37.7* mchc-33.9 rdw-16.1* 06:50pm neuts-62.6 lymphs-23.1 monos-8.5 eos-4.9* basos-0.9 06:50pm plt count-148* 06:50pm pt-17.8* ptt-37.0* inr(pt)-1.6* labs on discharge: 131 95 5 ------------<98 3.1 31 0.8 microbiology: 10:57 am urine source: cvs. **final report ** urine culture (final ): yeast. >100,000 organisms/ml.. 3:23 pm urine source: cvs. **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. yeast. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 1 s nitrofurantoin-------- 64 i tetracycline---------- =>16 r vancomycin------------ =>32 r 11:03 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): commensal respiratory flora absent. escherichia coli. rare growth. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. yeast. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | amikacin-------------- <=2 s ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s tobramycin------------ 8 i trimethoprim/sulfa---- =>16 r 9:39 am urine no growth. imaging: - chest (pa & lat) study date of 7:11 pm impression: markedly limited study. question increased density at the medial right lung base. this could represent superimposition of normal structures crowded by significant volume loss, however focal infiltrates cannot be entirely excluded. - portable abdomen study date of 9:07 am impression: two frontal views of the supine abdomen show disproportionate dilatation of the stomach and proximal small bowel with respect to relatively mild gaseous dilatation of the colon, probably the transverse. appearance is similar to ; small-bowel obstruction must still be considered. no nasogastric tube is seen despite severe gaseous distention of the stomach. right lung base is elevated, probably a combination of subpulmonic pleural effusion and upward displacement of the diaphragm. - ct abd & pelvis with contrast study date of 2:56 pm impression: 1. proximal small bowel dilatation measuring up to 3.6 cm with a point of transition in the right lower quadrant. imaging findings are consistent with partial versus complete obstruction likely on the basis of adhesions. 2. findings of hepatic cirrhosis as on prior exams. 3. anterior abdominal wall hernia containing mesenteric fat and fluid. - lung scan study date of impression: underventilated triple match v/q defect with low probability of pe. - unilat up ext veins us study date of 9:53 am impression: no evidence of deep vein thrombosis in the right arm. - ct abd & pelvis with contrast study date of 2:58 pm impression: 1. stable mild dilatation of the proximal small bowel loops, maximally measuring 3.6 cm. distal loops appear less distended, with possible transition point in the right lower quadrant, likely representing mild/partial small-bowel obstruction. 2. cirrhosis with moderate amount of abdominal and pelvic ascites. - ct head w/o contrast study date of 6:30 pm impression: 1. no acute intracranial hemorrhage or mass effect. if there is continued concern for parenchymal abnormalities, consider mr head if not contra-indicated. 2. mild diffuse volume loss increased from ct head study. - portable abdomen study date of 9:38 pm impression: in comparison to exam, there is mild improvement of ileus without complete resolution. - chest (portable ap) study date of 8:38 am findings: in comparison with the study of , the degree of pulmonary vascular congestion may have slightly improved. extensive bilateral atelectatic changes are again seen with blunting of the costophrenic angles consistent with pleural fluid. area of increased opacification in the right mid zone may merely represent atelectasis, though in the appropriate clinical setting the possibility of pneumonia would have to be considered. brief hospital course: summary statement: ms. is a 60 year old female with a provisional diagnosis of etoh cirrhosis who presented from rehab after a brief hospitalization for an mdr e.coli uti, new diagnosis of cirrhosis, and hyponatremia with chronic pain who was found to have an narcotic ileus who required tpn and then was transferred to the micu for concern for prolonged epistaxis from presumably ngt trauma who has remained encephalopathic with decompensated cirrhosis, persistent ileus from administration from narcotics, volume overload and hypoxia secondary to pulmonary edema and atelectasis prior to transfer to the micu: 1) narcotic ilues: prior to admission she presented with diffuse abdominal pain, and dilated small loops of bowl on kub. subsequent abdominal ct scans reveal potential transistion points and partial small bowel obstruction. she also developed non-bloody bilious emesis necessitating ngt placement and small bowel decompression. surgery was consulted and a small bowel follow through revealed and an ileus that was secondary to prolonged narcotic use for a presumed diagnosis of rsd. her narcotics were then stopped, but her ileus persisted which necessitated starting tpn, and subsequently her ileus resolved after methalynaloxone was administered. her pain from rsd was subsequently controlled with non-opioid analgesia including tramadol and lyrica. radiographs of the abdomin showed passing of contrast from the small bowel to the colon and her nutrition was transitioned from tpn to po. she was tolerating po prior to her transfer to the micu for epistaxis 2) decompensated cirrhosis: she presented with peripherial edema ascities without evidence of encephalopathy. however, she became mildly encephalopathic (grade i) with mild asterixis and disorientation (date) as her ileus persisted. she was given lactulose enemas which helped resolve her confusion. there was also concern that she may have sbp, although she was never febrile, and a a diagnostic paracentesis was negative. subsequently however, she underwent a therapeutic paracentesis to help remove ascites (3l removed) to improve her respiratory mechanics in addition to her ileus. she remained mildly encephalopathic until her transfer to the micu. 2) volume overload: she developed volume overload secondary to decompensated cirrhosis and portal hypertension, ascities, and the administration tpn in addition to iv medications and antibiotics. she was given albumin and prbc to maintain her map to help diuresis with aldactone and lasix. due to her uti, and concern for delerium, a foley was note placed to monitor uop. her weights were followed to monitor her fluid balance. 3) nutrition: due to her inability to tolerate po and narcotic ileus. she was started on tpn for several days. she also required additional potassium repletion due to diuresis for volume overload. 4) hyponatremia: she developed hypervolemic hyponatremia due to decompensated cirrhosis. her hyponatremia resolved after the administration of diurectics and free water restriction. 5) enterococcus/yeast uti. upon admission she was noted to have inflammation on her ua in addition to persistent yeast in her urine and vre. she was treated empirically for seven days for a complicated uti with linezolid and fluconazole. subsequent urine cultures were negative for persisent yeast or vre. 6) mdr e.coli uti: upon admission she was completing a course of tobramycin for an esbl uti, please see previous discharge summary for sensitivities. 7) anemia: the patient remained anemic on presentation and required multiple prbc transfusions for volume due to hypotension secondary to decreased intravascular volume. prior to her transfer to the micu she did not have evidence of active bleeding. micu course: patient transferred to micu given concern for hematemesis and upper gi bleed. was electively intubated for egd on . egd did not reveal presence of varices, but did show barrett's and gastropathy. patient continued on famotidine for gi ppx. there was no recurrence of hematemesis, and hct remained stable. patient did develop hypotension while intubated, likely multifactorial secondary to her underlying cirrhosis and to sedating medications. was briefly on pressors, but quickly weaned off once extubated. was successfully extubated . patient developed recurrent ileus while in icu; ngt kept to continuous low wall suction and patient kept npo. course notable for persistent ams, and patient was given lactulose enemas while npo. no evidence of infection, as patient afebrile without leukocytosis. diagnostic para negative for sbp. post micu course # encephalopathy: the patient's encephalopathy continued after she was transferred from the micu to the floor. she was aao x 1 with asterixis. she was treated heavily with lactulose po/pr, and began to put out an appropriate amount of stool, but without resolution of her encephalopathy. an infectious work-up with blood, urine, and chest x-ray was negative. opioid medications, which were given to her in the icu, were avoided on the floor. the patient's encephalopathy cleared on , when she was aaox3, and was following commands, but with occasional asterixis. she no longer required restraints, and had not been using the olanzapine which was written for her prn for agitation. her encephalopathy was felt likely secondary to lingering opioid medication, and not to hepatic encephalopathy given her appropriate output of stool. # epistaxis: upon transfer back from the icu, the patient did not have any signs of epistaxis, and did not require any transfusion. # ileus: the patient had an ileus that was noted on abdominal x-ray upon return from the icu, which was felt likely secondary to opioid medication. the patient was made npo, and started on metoclopromide. a few days later the patient's gi motility started to return, and her diet was gradually advanced, and her medications were returned to po. opioid medication was again thought to play the largest role in the patient's ileus. metoclopromide was discontinued on patient's discharge. # tachypnea: the patient was noted on the floor for tachypnea during her stay, with a normal abg and normal o2 sats. her tachypnea was felt to be secondary to abdominal ascities with ateletasis and an element of volume overload. she was treated on the floor with iv lasix, and ultimately her o2 requirements were removed. the patient was started on a dose of 40 mg lasix po bid and her home dose of spironolactone (50 mg daily). she was discharged on her home dose of 40 mg lasix daily and a new dose of 100 mg spironolactone daily without tachypnea. # decompensated cirrhosis: underlying etoh cirrhosis. no history of varices or sbp; egd from confirmed patient does not have varices, and diagnostic para not suggestive of sbp. the patient was continued on lactulose and rifaximin. # hypernatremia/hyponatremia: the patient transiently became hypernatemic with na of 154 after diuresis, which resolved with free water administration. on discharge she was hyponatremic without end organ signs likely secondary to diuresis. # nutrition: given resolving ileus and multiple bm, the patient was discharged on regular diet low salt/heart healthy diet # pain: the patient's chronic leg and back pain had previously been treated with opiod medication, but her hospital course was complicated by several adverse events secondary to opioid medication (ileus, encephalopathy). her morphine doses were discontinued, and the patient was started in house on standing tylenol for pain control. # history of restless legs: the patient previously had been on mirapex 1mg qhs for restless legs. this was stopped while in the hospital, but may be restarted as needed. medications on admission: 1. alendronate 70 mg po qweekly 2. morphine 30 mg po q12h 3. morphine 15 mg po q6h prn 4. omeprazole 20 mg po daily 5. potassium chloride 20 meq po bid 6. mirapex 1 mg po qhs 7. trazodone 300 mg po qhs 8. hydroxyzine hcl 25 mg po q6h prn 9. lactulose 30ml po tid 10. phenazopyridine 100 mg po tid prn 11. triamcinolone acetonide 0.1 % cream topical 12. lidocaine 5 %(700 mg/patch) adhesive patch daily 13. zofran 8 mg po qid prn 14. calcium citrate + d 630-400 mg-unit po bid 15. vitamin d-3 1,000 unit po daily 16. cyanocobalamin (vitamin b-12) 1,000 mcg po daily 17. docusate sodium 100 mg po bid 18. centrum silver po daily 19. furosemide 40 mg po daily 20. spironolactone 50 mg po daily 21. rifaximin 550 mg po bid 22. tetracycline 500 mg po qid last day 23. azithromycin 250mg daily (started at rehab) 24. albuterol nebulizer (started at rehab) discharge medications: 1. alendronate 70 mg tablet sig: one (1) tablet po once a week. 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 3. potassium chloride 10 meq capsule, extended release sig: two (2) capsule, extended release po twice a day. 4. trazodone 300 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 5. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po every six (6) hours as needed for itching. 6. lactulose 10 gram/15 ml solution sig: thirty (30) ml po three times a day. 7. phenazopyridine 100 mg tablet sig: one (1) tablet po three times a day as needed for pain. 8. triamcinolone acetonide 0.1 % cream sig: one (1) application to affected areas topical twice a day. 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) patch topical once a day. 10. zofran 8 mg tablet sig: one (1) tablet po four times a day as needed for nausea. 11. calcium 600 with vitamin d3 600 mg(1,500mg) -400 unit capsule sig: one (1) capsule po twice a day. 12. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet, chewable po once a day. 13. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1) tablet po once a day. 14. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 15. centrum silver tablet sig: one (1) tablet po once a day. 16. furosemide 40 mg tablet sig: one (1) tablet po once a day. 17. rifaximin 550 mg tablet sig: one (1) tablet po twice a day. 18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) puff inhalation every 4-6 hours as needed for shortness of breath or wheezing. 19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation every four (4) hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*3* 20. acetaminophen 500 mg capsule sig: one (1) capsule po every six (6) hours. disp:*120 capsule(s)* refills:*0* 21. artificial tears(glycerin-peg) 1-0.3 % drops sig: one (1) drop to both eyes ophthalmic prn as needed for dry eye. disp:*1 tube* refills:*0* 22. spironolactone 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: - and vre cystitis - opioid-induced ileus - hepatic encephalopathy secondary diagnosis: - etoh cirrhosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: ms. , it was a pleasure taking care of you in the hospital. you were admitted to the hospital with diffuse body pain. you were found to have an infection in your bladder, and we treated you with the appropriate antibiotics. however, your hospital course was complicated by a slow moving gi tract that likely happened because of the high dose of narcotics which you normally take. we confirmed that you did not have an obstruction in your abdomen, and gave you some medications to help your gut move along. during that time when you were not eating, we were giving your nutrition through your veins. also during your hospital stay, you had started vomiting some blood; we took you to the icu were we put a breathing tube down your throat and also looked at your stomach lining, where we did not see any bleeding. we believe that your vomiting of blood may have been blood which dripped into your stomach from your nose. unfortunately, when you were intubated, we needed to give you more doses of narcotics, which caused your gi tract to slow down again. your gut motility improved, but you still remained a little bit confused, which improved once the narcotics had worked their way out of your system. when you leave the hospital: - stop morphine 30 mg every 12 hours - stop morphine 15 mg every 6 hours as needed for pain - stop tetracycline 500 mg four times a day - stop azithromycin 250 mg every day - stop mirapex 1mg before bedtime - start ipratropium bromide inhaler 1 puff inhalation every four (4) hours as needed for shortness of breath or wheezing - start acetaminophen 500 mg every 6 hours - start artificial tears(glycerin-peg) 1-0.3 % drops: use one (1) drop to both eyes as needed for dry eyes - increase your dose of spironolactone to 100 mg daily (previously you had been taking 50 mg daily) we did not make any other changes to your medications, so please continue to take them as you normally have been. followup instructions: when you leave the hospital, please have your rehab facility make the following appointments for you: - make an appointment to see your primary care doctor, dr. , one week after your discharge from rehab by calling department: liver center when: wednesday at 10:00 am with: , md building: lm campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances other endoscopy of small intestine insertion of endotracheal tube percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage arterial catheterization injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: anemia of other chronic disease other chronic pain alcoholic cirrhosis of liver hyposmolality and/or hyponatremia portal hypertension unspecified acquired hypothyroidism candidiasis of other urogenital sites other opiates and related narcotics causing adverse effects in therapeutic use long-term (current) use of other medications osteoporosis, unspecified infection with microorganisms without mention of resistance to multiple drugs paralytic ileus accidents occurring in other specified places other ascites hypoxemia surgical or other procedure not carried out because of patient's decision other encephalopathy streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] obesity, unspecified hematemesis other specified disorders of stomach and duodenum unspecified sedatives and hypnotics causing adverse effects in therapeutic use backache, unspecified barrett's esophagus other and unspecified alcohol dependence, continuous venous (peripheral) insufficiency, unspecified reflex sympathetic dystrophy, unspecified pain in limb body mass index 40.0-44.9, adult cystitis, unspecified 

Answer: The patient is high likely exposed to