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 / ciprofloxacin attending: chief complaint: fever major surgical or invasive procedure: mechanical ventilation icu monitoring picc line placement x2 central line placement history of present illness: mr. is a 49-year-old male with a history of apml s/p induction and consolidation chemotherapy, who has been on a maintenance program with 6 mp, then methotrexate, and atra, who was found to have recurrent disease and was recently admitted for midam chemotherapy and discharged two days prior to admission. the patient reports having "really bad diarrhea" two days prior to admission in the evening. he had two more episodes of diarrhea on the evening prior to admission. he has had some mild abdominal cramping/discomfort, but no abdominal pain. he has had some intermittant nausea, but no vomiting. there is no blood in his stool. he has also had pain near his anus for the past 3 days which disappeared after he received his first antibiotic infusion in clinic today. the patient came to clinic for routine labs today. he was noted to be thrombocytopenic and received a platelet transfusion. afterward, his temperature rose to 102 despite receiving acetaminophen prior. he had blood cultures drawn both peripherally and from his picc line. he received 1 l normal saline and aztreonam 2000mg iv infusion. on arrival to the floor he was febrile to 102.5 and vancomycin and flagyl were hung. ros: as above. additionally notable for poor appetite and low energy which are stable since his chemo and some intermittant lightheadedness. negative for headache, recent vision or hearing changes, runny nose, sore throat, cough, shortness of breath, chest pain, palpitations, brbpr, dysuria, rashes, myalgias, or arthralgias. past medical history: 1. acute promyelocytic leukemia 2. s/p cholecystectomy 3. irritable bowel syndrome 4. history of hypercholesterolemia 5. history of anal fissures social history: negative for tobacco, rarely drinks etoh. he lives with his wife and 6 yr old son. owns a seafood company and is a former stock broker. he has no known chemical exposures. his only foreign travel is to . he has a dog. family history: his father died of prostate cancer and also had dm and heart disease. he has a cousin with cancer. no known family with leukemia or lymphoma. physical exam: vs: t 102.5, bp 138/74, hr 124, rr 20, 96% on ra general: middle-aged caucasian male, appears tired, but comfortable. heent: sclerae anicteric. perrl, eomi. oropharynx is clear, no exudates or erythema. no oral lesions. mmm. neck: no cervical, supraclavicular, or axillary lymphadenopathy. heart: tachycardic, regular rhythm, normal s1, s2. no m/r/g. lungs: ctab. no crackles, wheezes or rhonchi. abd: soft, obese, ntnd. no hsm appreciated. rectal: peri-anal tissue with mild erythema near the anus, but no obvious swelling, bleeding, or exudate. no tenderness to palpation of the peri-anal tissues. extremities: no edema. 2+ dp pulses bilaterally. right picc line with small amount of dried blood under dressing but no tenderness to palpation. skin: no rashes neuro: alert and oriented x 3, cnii-xii grossly intact, language appropriate, moves all extremities symmetrically. pertinent results: course labs: labs on admission to : 12:00am blood wbc-0.1* rbc-3.49* hgb-10.7* hct-28.7* mcv-82 mch-30.7 mchc-37.2* rdw-13.8 plt ct-7* 12:00am blood neuts-0* bands-0 lymphs-100* monos-0 eos-0 baso-0 atyps-0 metas-0 myelos-0 08:13pm blood pt-21.6* ptt-48.2* inr(pt)-2.1* 12:40pm blood glucose-104 urean-16 creat-1.0 na-130* k-3.8 cl-100 hco3-16* angap-18 12:00am blood alt-419* ast-404* ld(ldh)-738* alkphos-63 totbili-3.0* dirbili-1.1* indbili-1.9 08:50pm blood type-art po2-72* pco2-32* ph-7.40 caltco2-21 base xs--3 . microbiology data: blood: blood culture, routine (final ): proteus vulgaris. final sensitivities. escherichia coli. final sensitivities. proteus vulgaris | escherichia coli | | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s levofloxacin----------<=0.25 s meropenem-------------<=0.25 s <=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s =>16 r . remaining blood cultures: negative or no growth to date. . sputum: mini-bal: no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth. . gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). all other sputum cultures negative. . immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii). . urine: all urine cultures negative. . peritoneal fluid: 2:53 pm peritoneal fluid. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): pending acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): pending fungal culture (preliminary): pending . misc: cmv viral load (final ): cmv dna not detected. . imaging: serial ct scans: ct w/contrast : inflammation associated with the duodenum, extending along the retroperitoneum. findings most likely represent duodenitis. perforated duodenal cannot be excluded, although no extraluminal air is identified. pancreatitis with secondary duodenal inflammation is less likely. . ct abd/pelvis w/o contrast study date of 6:04 pm: 1. progressed appearance of inflammation with increased ascites. stranding is seen around the duodenum, right perinephric area and pancreas. regarding pancreatitis or renal pathology, recommend correlation with labs since this may be a secondary inflammatory process. 2. no conclusive evidence for perforation but given the inflammatory changes around the duodenum, the appropriate clinical setting, could consider a repeat scan in hours to evaluate for extravasation and perforation. . ct abdomen/pelvis w/o contrast study date of 9:25 pm: 1. extensive inflammatory change in the peritoneum and retroperitoneum, with free fluid and stranding as previously, though no evidence of extraluminal leak of oral contrast. 2. increase of right pleural effusion . ct abdomen/pelvis w/o contrast study date of 8:52: 1. progression of intra-abdominal free fluid and minimal change in the overall degree of intra-peritoneal stranding. there is no evidence of extraluminal leak of contrast or obstruction. 2. progression of right lung effusion and tree-in- opacities which may be secondary to the diffuse process involving the abdomen though should be clinically correlated for possible infection in the setting of neutropenia. . ct torso w/o contrast : 1. interval worsening of the consolidation of the bilateral lower lobes. this finding may represent atelectasis, however, superimposed infection cannot be excluded. there are small bilateral pleural effusions. 2. interval increase in the amount of ascites since the prior exam with a moderate amount now present. . ct abdomen/pelvis w/o contrast study date of 1. persistent -basilar, left greater than right, pulmonary consolidations. this may represent atelectasis, however, superimposed pneumonia cannot be excluded. small bilateral pleural effusions are improved. 2. mild jejunal wall thickening is non-specific but could reflect opportunistic infection. 3. persistent moderate intra- abdominal ascites, with no evidence of loculated abscess formation. . unilat up ext veins us port left study date of : 1. thrombosis of the left basilic vein with no upstream extension. 2. hypoechoic well-defined mass of the right forearm measuring 1.8 cm. differentials include thrmbosed superficial vein and soft tissue tumor. . most recent portable cxr : there are low lung volumes which slightly limits assessment, particularly in the lower lungs which have some associated volume loss. ng tube is in the stomach. right upper quadrant clips are present. there is right ij line with tip in the svc. there is no pneumothorax. . ct head : 1. new right frontal hemorrhagic contusion with probable small regions of adjacent subarachnoid hemorrhage. known external soft tissue swelling. no skull fractures. close follow up as clinically indicated. findings were discussed with dr. on date of exam at 9:40 a.m. this study done on at 03.43am is available for review on at 9.30am and wet rea dwas given to the physician as mentioned above. 2. small amount of fluid in the mastoid and petrous apices on both sides, new since prior. . ct head : 1. no interval change to right frontal partially hemorrhagic contusion with small regions of adjacent subarachnoid hemorrhage. f/u a sindicated clinically. other details above . labs on discharge: : wbc 4.9 hbg 9.6* hct 27.7* platelets 377 coags: pt 14.6* ptt 28.3 inr 1.3* chem 7: gluc 91 bun 16 crn 0.8 na 138 k 3.8 cl 101 hco3 25 brief hospital course: in brief, mr. is a 49-year-old male with a history of apml s/p multiple rounds of chemotherapy who recently underwent midam chemotherapy, being treated with atra and was admitted with febrile neutropenia and diarrhea and found to have gnr sepsis and duodenitis. . # febrile neutropenia, gnr sepsis: the patient was initially covered empirically with vancomycin, aztreonam, and flagyl with concern for a gi source given his recent diarrhea and history of anal fissures. he had no respiratory or urinary symptoms on presentation and initial chest x-ray was negative for pneumonia. initial ct scan on was concerning for duodenitis and the patient's antibiotic regimen was broadened to include ciprofloxacin and micafungin and blood cultures from the previous day were positive for gram negative rods. overnight, the patient's lfts rose and he had multiple electrolyte abnormalities that were corrected intravenously. surgery was consulted early on the morning of given continued fevers and worsening abdominal pain. an abdominal ultrasound was obtained and showed no evidence of -occlusive disease or intrahepatic duct dilatation. the patient's lfts continued to rise during the day, his inr and ptt also rose, and additional labs were concerning for dic. the patient was transfused with multiple units of platelets and also received prbcs, ffp, and vitamin k to try to correct his coagulopathy. the patient had an episode of diarrhea on that consisted of black-colored liquid. he was placed on pantoprazole iv bid for gi bleeding. a repeat ct scan in the evening with gastrograffin demonstrated increased inflammation, but negative for duodenal perforation. as his lactate was rising and his platelets remained very low despite several transfusions in the context of a neutrophil count of 0, he was then taken to the for further management. in route to the , a ct abd was done which showed extensive inflammatory changes in the peritoneum and retroperitoneum. the cause was unclear but thought perhaps to be related to his atra, which was held. surgery followed him and thought that there was no indication for surgical management. repeat ct the following day showed progression of intra-abdominal free fluid and minimal change in the overall degree of intra-peritoneal stranding. his abdomen continued to be distended and tender, and he was increasingly short of breath and hypoxic. he was eventually intubated for airway protection. blood cultures grew proteus and e coli from . he underwent meropenem desensitization followed by meropenem treatment. empiric acyclovir at treatment doses was also started. filgrastim was also started for neutropenia. patient was followed by id and started had the following courses of antibiotics: vanco (), linezolid (), metronidazole (, ), voriconazole ( ?????? ). neutropenia resolved as of . patient was treated for a total of two weeks of vancomycin and meropenum following recovery of his counts on , consequently last day of therapy was . patient continued to have low grade fevers while on meropenum and vancomycin. infectious work-up involved mini-bal negative gram stain; multiple negative blood cultures and urine cultures; negative b-glucan and aspergillus; c. diff negative x 3; diagnostic para negative gram stain and cultures negative. . # lue dvt: during the workup for the patient's fever on meropenem and vancomycin, the patient was found to have dvt in the left upper extremity at the site of a picc. patient was started on heparin drip and was initially started on coumadin, but changed to lovenox. low grade fevers felt to be secondary to clot, and eventually resolved. on the night of , the patient fell standing up from the bed while on lovenox, see below. lovenox was discontinued. the decision was made not to restart lovenox as the dvt was likely induced by the picc placement and small enough not to require long term anticoagulation. . # respiratory distress: the patient was intubated in the setting of abdominal distension and pain, no obvious primary pulmonary process. the patient was successfully extubated on using precedex. . # thrombocytopenia: initially related to the patient's recent chemotherapy. he was initially transfused to keep his platelets > 10k. subsequently, however, he did not bump his platelets appropriately to transfusion, likely as a result of dic and his acute illness, and given his gi bleeding, his transfusion threshold was increased. once his acute illness resolved, his platelet count was maintained over the next week without transfusions. . # acute promyelocytic leukemia: the patient was initially continued on atra per his home regimen, however, his dose was reduced to 30 mg po bid on the morning of given the worsening of his acute illness. in the , atra was discontinued. the patient was instructed to discuss restarting this medication with his primary oncologist dr. on discharge. . # subarachnoid hemorrhage: in the setting of anticoagulation with lovenox. the patient was given protamine and vitamin k. head ct showed small subarachnoid hemorrhage and neurosurgery was consulted. repeat head ct the following day did not show change in the hemorrhage. neurosurgery recommended maintaining platelet count > 60-70 and if < 100 should repeat head imaging. the patient should follow up with dr. in 4 weeks with repeat head ct at that time. . # history of anal fissures: the patient was continued on analpram. . # dysuria: no evidence of uti on ua or urine cultures. started following discontinuation of foley catheter. most likely traumatic in nature. used lidojet and pyridium for symptomatic relief. medications on admission: docusate sodium 100 mg hydrocortisone-pramoxine 2.5-1 % cream, apply prn anal fissure. lorazepam 0.5-1 mg q4h prn anxiety, nausea nystatin 100,000 unit/ml suspension, 5 ml qid prn thrush oxycodone 5 mg po q8h prn pain caphosol 30 cc po qid prn mouth sores sennosides 8.6 mg prn constipation atra 50 mg po qam, 40 mg po qpm discharge medications: 1. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 2. analpram-hc 2.5-1 % cream sig: one (1) rectal once a day as needed for pain. 3. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for mouth pain, thrush. 4. ativan 0.5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for anxiety. 5. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. 6. saliva substitution combo no.2 solution sig: one (1) ml mucous membrane qid (4 times a day) as needed for mouth sores. 7. senna 8.6 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 8. 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. 9. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 10. acyclovir 200 mg capsule sig: two (2) capsule po q8h (every 8 hours). disp:*3 capsule(s)* refills:*2* 11. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). disp:*60 tablet(s)* refills:*2* 12. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) for 3 days. disp:*9 tablet(s)* refills:*0* 13. famotidine 20 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: primary diagnoses: gram negative rod bacteremia acute hepatitis from drug toxicity duodenitis/colitis acute promyelocytic leukemia subarachnoid hemorrhage deep vein thrombosis of the upper extremity. . secondary diagnoses: hypercholesterolemia s/p cholecystetomy discharge condition: the patient was afebrile and hemodynamically stable prior to discharge. discharge instructions: you were admitted to for evaluation of abdominal distension. you were found to have an infection in your bowel that infected your blood stream. you had a complicated hospital course where you were treated with iv antibiotics for many days. you had to be intubated and maintained on a mechanical ventilator for a period of time because of your illness. you were weaned off the ventilator and worked with physical therapy to regain your strength. your antibiotics were discontinued and you will only need to continue on antibiotics for prophylaxis as an outpatient. . you will need to follow up closely with your primary oncologist. . medication changes: start ursodiol 300 mg 3 times a day start acyclovir 200 mg capsule two (2) capsules every 8 hours start fluconazole 200 mg tablet two (2) tablet every day start famotidine 20mg twice a day start phenazopyridine 100 mg tablet 3 times a day as needed for pain with urination for 3 days stop atra (please discuss with dr. when to restart this medication) . if you experience chest pain, fevers, shortness of breath, abdominal pain, diarrhea, constipation, worsening pain with urination or any other concerning symptoms please seek medical attention. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube other bronchoscopy arterial catheterization transfusion of packed cells transfusion of other serum transfusion of platelets injection or infusion of oxazolidinone class of antibiotics diagnoses: acidosis thrombocytopenia, unspecified other and unspecified noninfectious gastroenteritis and colitis anemia, unspecified pure hypercholesterolemia acute and subacute necrosis of liver acute kidney failure, unspecified severe sepsis unspecified fall acute respiratory failure other septicemia due to gram-negative organisms other ascites duodenitis, without mention of hemorrhage septicemia due to escherichia coli [e. coli] examination of participant in clinical trial hepatitis, unspecified acute pancreatitis neutropenia, unspecified anal fissure disorders of bilirubin excretion unspecified peritonitis acute myeloid leukemia, without mention of having achieved remission subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness edema universal ulcerative (chronic) colitis stomatitis and mucositis, unspecified 

Answer: The patient is high likely exposed to