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: morphine / betalactams / iodine; iodine containing attending: chief complaint: fever, jaw pain major surgical or invasive procedure: # l cervical lymph node biopsy # elective intubation # ng tube placement # picc placement history of present illness: 68 y/o f with cll presented to ed with fever and jaw pain. at osh, pt seen by dental who did not feel there was any abscess or intervenable process. ct head also confirmed lack of abcess. she was started on clinda and xferred to for further care. here she also reports headache, flu like symptoms. in the ed she received a dose of cefepime and she was admitted to omed. ros: pt notes that jaw pain and fevers started yesterday, but she has had a few days of dry cough, achyness and fatigue. today has some mild abd discomfor which she attributes to not eating. denies back pain, dysuria, n/v, diarrhea, chest pain, or sob. denies sick contacts. she does report increase over the last few weeks. past medical history: -cll: dx in by periph blood flow cytometry. ct scan showed abdominal & cervical lad, and large right pelvic mass. excisional biopsy of left supraclavicular node pathology and immunohistochemistry c/w cll. bm bx revealed extensive infiltration, with 40% marrow cellularity. pt was asympt & deferred tx until f/sweats in & tx was started w/fludarabine (). rituxan was added to 2nd cycle. however her chemotherapy course was complicated by febrile neutropenia. after two cycles of fludarabine this was changed to single rituxan, and she completed four weeks of consolidation. her post-chemotherapy course was complicated by febrile neutropenia and pancytopenia. her bone marrow was again assessed in and was consistent with treated cll. she remained thrombocytopenic following this without a response to steroids and only minimal response to ivig. rituxan weekly was given from through and platelets recovered to about 30,000. bone marrow biopsy on suggested a sustained response to chemotherapy on the megakaryocytes. she began maintenance rituxan on , but her course was complicated by diffuse arthralgias. due to increasing painful lymphadenopathy and ivc compression seen on ct, she was treated with chlorambucil from through . this was then stopped due to thrombocytopenia. chlorambucil was restarted at 4mg dose on when she progressed with painful adenopathy. this was given concurrently with prednisone to treat itp. the chlorambucil was discontinued on . a second course was again started on . - htn with multiple admissions for hypertensive urgency. most recent admission with neurological complaints that resolved on outpatient regimen - cad: diffuse multi-vessel disease. lad stent - chf - high cholesterol - hypothyroid - chronic renal insufficiency with baseline cr about 1.3 - anemia - gout - dm 2 social history: from . married. works as cashier. denies t/a/d family history: the patient notes a mother with a myocardial infarction at the age of 71. a sister with a myocardial infarction at the age of 47. otherwise, denies any further family history. physical exam: vs: tm 101 153/59 66 16 96% ra gen: tired-appearing female, nad heent: perrl, eomi, mm dry, op clear, mild swelling, tenderness and erythema over left posterior mandible/upper neck. cv: rrr, nl s1/s2, 2/6 systolic murmur pulm: cta b abd: soft, mildly obease, nt/nd, +bs, no masses ext: 1+ pitting edema bilaterally, warm skin, 2+ distal pulses skin: no rashes, or jaundice 1+ bilat pertinent results: on admission: wbc-23.9* hct-27.6* mcv-97 plt ct-23* neuts-19* bands-0 lymphs-75* monos-5 eos-0 baso-1 atyps-0 metas-0 myelos-0 . glucose-125* urean-46* creat-2.0* na-139 k-4.1 cl-99 hco3-33* lactate-0.6 . pt-12.9 ptt-22.2 inr(pt)-1.1 . alt-8 ast-12 ld(ldh)-193 alkphos-46 totbili-0.3 . relevant hospital course labs: cardiac enzymes: 02:53am ck-mb-2 ctropnt-<0.01 07:35pm ck-mb-3 ctropnt-<0.01 . thyroid function tests: tsh-8.0* t3-100 free t4-1.3 . tsh-0.16* free t4-1.4 . discharge labs: wbc-14.7* rbc-2.56* hgb-8.3* hct-25.1* mcv-98 mch-32.4* mchc-33.1 rdw-15.2 plt ct-23* . glucose-232* urean-63* creat-1.7* na-139 k-4.7 cl-109* hco3-22 angap-13 . alt-84* ast-15 ld(ldh)-269* alkphos-33* totbili-0.6 . ct chest/abd/pelvis: impression: 1. increased size of multiple pathological ly enlarged lymph nodes within the chest, abdomen, and pelvis since . 2. no evidence of obstruction. . ct neck w/o contrast (eg: parotids) impression: 1. extensive supra- and infra-hyoid lymphadenopathy with severe narrowing of the laryngopharynx. . bone marrow biopsy diagnosis: cellular marrow with maturing trilineage hematopoiesis, mild megakaryocyte hypoplasia and minimal involvement by the patient's known chronic lymphocytic leukemia/small lymphocytic lymphoma. . left cervical lymph node biopsy diagnosis: involvement by the patient's known small lymphocytic lymphoma/chronic lymphocytic leukemia (sll/cll); no diagnostic morphologic features of transformation to large cell lymphoma seen. . repeat ct neck impression: 1. marked decrease in the size of the lymphadenopathy in the cervical and supraclavicular regions diffusely. 2. right subclavian central venous catheter tip extending into the left brachiocephalic vein, and should be repositioned for more appropriate placement. . echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal(>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. compared with the prior report (images unavailable for review) of , biventricular systolic function remains preserved. mild pulmonary artery systolic hypertension is now identified. . unilat up ext veins us right impression: right-sided picc line seen in the right basilic vein. thrombus seen surrounding the line in the basilic vein. remaining right-sided veins appear patent. . unilat up ext veins us left impression: picc in the left brachial vein. no evidence of deep venous thrombosis . 3:40 am blood culture **final report ** blood culture, routine (final ): no growth. . 4:10 am urine **final report ** urine culture (final ): <10,000 organisms/ml. . 8:11 am blood culture source: line-picc. **final report ** blood culture, routine (final ): no growth. . 8:12 am urine source: catheter. **final report ** urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- =>64 r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- =>128 r piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r aztreonam = resistant. . 1:59 pm sputum + bronchoalveolar lavage source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): moderate growth oropharyngeal flora. legionella culture (final ): no legionella isolated. . 1:16 pm urine source: catheter. **final report ** urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- =>64 r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- =>128 r piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r brief hospital course: 66yo f with cll presented with fevers and left sided jaw pain . #) lymphadenopathy / airway compromise: although patient was admitted for jaw/tooth pain, she was noted to have significant facial edema and odynophagia. after outside records were reviewed, it was discovered that patient did not have dental evaluation as previously reported, but instead had ct scan which was concerning for airway compromise. ct scan of neck and torso was performed here and revealed severe narrowing of the airway at the level of the oropharynx. orl service and radiation oncology were consulted regarding therapeutic options. orl service noted narrowing in upper airway and edema which would make emergant intubation difficult. etiology of edema thought to be to extensive lymphadenopathy decreasing lymphatic draingage. given relatively new airway compromise and affect on treatment recommendations particularly by radiation oncology for treatment dose and potential response, concern raised for transformation of ccl. left supraclavicular ln excision () was performed and showed cll. initial biopsy plans had been delaye3d by hypertensive urgency thought related to her underlying difficult to control bp in the setting of steroids. bone marrow biopsy done () to re-evaluate etiology of thrombocytopenia in preparation for chemotherapy decision-making. these showed stable, non transforming disease. dexamethasone 40mg was given when airway compromise first suspected and tumor lysis labs monitored. . patient became dyspneic and tachypneic on the floor, and was transferred to micu for closer monitoring as there was significant concern regarding airway patency. she was electively intubated and sedated for airway protection in preparation for ln biopsy and subsequent planned radiation (to protect against radiation induced edema and need for urgent intubation). she received radiation treatments on and , and had daily cuff leaks checked. swelling from radiation did reach the point that on the morning of she had no cuff leak; this resolved over time while getting further radiation ( and throughout remainder of hospitalization). she was extubated on . after this she complained of burning pain in her throat, which was likely related both to her nasotracheal intubation and to the radiation to her throat. she developed thrush on her last day of her micu stay. speech and swallow service saw her and felt that she would have a difficult time with swallowing anything, and nutrition was a concern when she was transferred to the oncology service from the icu. . when transferred back to the oncology service, she was still complaining of some difficulty breathing, had severe thrush, had an ng tube in place, and her sodium was 149. we continued tube feeds per nutrition recommendations but added aggressive free water boluses and d5w via iv to lower her sodium. her nystatin s/s was changed to fluconazole 7 day course (completed with significant improvement). she continued to receive daily xrt to the throat and neck, and remained on a slow steroid taper to control her swelling (10mg daily at time of d/c). her oropharyngeal and neck edema continued to improve. speech and swallow was reconsulted and she was deemed able to tolerate po. her ngt was pulled and pt quickly tolerated a regular diet. in addition, her sodium quickly normalized and remained stable once on po. . she is next due for xrt on , and had completed sessions by discharge. . #) fever: on admission, it was felt that most likely etiology was soft tissue/dental infection. here, patient was febrile to 101.2 without obvious source of infection. patient initially placed on cefepime for febrile neutropenia while cultures were made available. patient noted to have history of agranulocytosis with beta-lactams; antibiotic regimen changed for levaquin and clindamycin for 14 day course. however, once transferred to the micu, after biopsy showed cll in her lymph nodes and there was no evidence of jaw infection, antibiotics were stopped. . however, on she developed fevers while on the vent, up to 101.3, and was treated for vap based on gram stain showing gpcs. we continued treating with vanco, levo, flagyl (a second-line approach because of her beta-lactam allergy) with a planned 7 day course for vap. an initial urine culture was positive, with sensitivities primarily to medicines we could not use because of the patient's apparent beta-lactam allergy; whether this was really a significant uti was unclear at the time of transfer from the . however, a repeat urine culture on again showed >100k of esbl e. coli, although she was assymptomatic. id was curbsided, and she was briefly treated with aztreonam, but the organism ended up being resistant to this as well. we considered using meropenem, but given her allergy history this was deferred. foley catheter removed and pt followed off antibiotics for symptoms and evidence of fever. neither occured and pt was not discharged on antibiotics. #) hypertension: patient had history of malignant hypertension in prior admissions with symptoms of headache and epigastric / left sided chest pain. patient experienced new episode during this hospitalization after discontinuation of lisinopril after this was held for worsening renal insufficiency, in spite of addition of hydralazine po prn for sbp > 160 and q4h vital signs. patient was ruled out for mi and likely experienced this episode secondary to dexamethasone therapy. an echo was done and showed mild pulmonary artery hypertension and preserved systolic function with lvef >55%. her pressures became elevated during the latter part of her micu stay but she was having great difficulty with swallowing, so she was put on iv metoprolol and hydralazine to control pressures as needed; she was also started on a clonidine patch. she was gradually transitioned back to her extensive home antihypertensive regimen on the floor, with the substitution and uptitration of carvedilol for beta blockade . #) atrial fibrillation - on pt was noted to be in an irregular rhyhtm and ekg confirmed afib. due to her chronic low platelets she was not a candidate for anticoagulation. cardiology was consulted and agreed with rate control management alone, so her beta blocker was uptitrated to carvedilol 37.5mg . she did not experience chest pain, palpitations, or rvr. . #) acute renal failure / chronic renal failure: although patient has known chronic renal insufficiency, she was noted to be above her baseline at admission. renal ultrasound was obtained and did not reveal any obstruction. urine electrolytes revealed feurea greater than 40% and nephrotoxic drugs were stopped. renal team was consulted and helped in management. creatinine had improved significantly at time of micu transfer, but did go up and down somewhat during her stay. the cause of her next worsening while in the (a return to peak of 2.2) may have been the initiation of steroids. on the floor, with aggressive rehydration for hypernatremia (max was 151), her creatinine decreased to baseline. the fact that she could eat and drink on her own likely contributed to this normalization. . #) anemia/thrombocytopenia: hct 27, plt 23 on admission, both of which are below her baseline. patient's hematocrit decreased to 23.5 and given transfusion of 1 unit of prbc. patient received 2 units of platelets prophylactically for biopsy of lesions. per marrow crowding out, as per reuslts of recent bm bx. rather, it may be itp related (commonly seen in cll). cbc's were checked daily with criteria for transfusion being hct 21 and platelets of 10. . #) throat pain: after extubation she complained of debilitating throat pain, which made po medicines very difficult. we transitioned several to iv during this period and treated pain with prn meds. she was diagnosed with thrush on her day of transfer from the . as mentioned above, she completed a course of fluconazole for thrush, which was markedly improved by discharge. of note, her lfts did bump during this treatment, likely as a medication side effect. . #) cll: last dose chlorambucil in early . was in 4 week "off" period during hospitaliztion. restarted at time of discharge, and outpatient management deferred to primary heme/onc team. . #) cad: although patient experienced malignant hypertensive episode with associated chest pain, there were no ecg changes and cardiac enzymes were negative x 3. aspirin therapy was considered but not given due to thrombocytopenia. medical cad regimen included bb, ace-i, and nitrate #) dm: fixed dose (glargine 9 units ) and sliding scale insulin while in house. glyburide restarted prior to discharge after patient demonstrated acceptable po intake. continued gapapentin per home regimen. . #) hypothyroidism: we initially continued her synthroid at outpatient dose. although tsh was high, t3 and free t4 levels were within normal limits. however, when she developed new afib, thyroid studies were again checked. these showed a moderately suppressed tsh at 0.16, with normal t4 levels. endocrine was curbsided and recommended continuing her levothyroxine, but at 75mcg daily instead of 88 mcg daily. . #) fen: heart healthy diet, checked lytes and replete prn. #) access: l picc placed (previously had r picc but d/c'ed thrombus) #) ppx: pneumoboots, ppi because of high dose steroids, bowel regimen. #) code: full #) comm: with patient, patient's family. medications on admission: 1. hydrochlorothiazide 25 mg daily. 2. isosorbide dinitrate 60 mg daily. 3. levothyroxine 88 mcg daily. 4. glipizide 5 mg b.i.d. 5. norvasc 10 mg b.i.d. 6. trazodone 50 mg q.h.s. p.r.n., sleeplessness. 7. lasix 40 mg daily. 8. lisinopril 40 mg daily. 9. gabapentin 400 mg q.h.s. 10. propranolol ? 125 mg daily. 11. celexa 20 mg daily. 14. erythromycin eye ointment. discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po bid (2 times a day). 2. erythromycin 5 mg/g ointment sig: 1-2 drops ophthalmic qid (4 times a day). 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 4. glipizide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 6. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 7. gabapentin 400 mg capsule sig: one (1) capsule po hs (at bedtime). 8. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 9. carvedilol 12.5 mg tablet sig: three (3) tablet po bid (2 times a day). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 14. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qfri (every friday). 15. gabapentin 400 mg tablet sig: one (1) tablet po at bedtime. 16. isosorbide dinitrate 20 mg tablet sig: two (2) tablet po q 8h (every 8 hours). 17. lasix 40 mg tablet sig: one (1) tablet po once a day. 18. maalox 200-200-20 mg/5 ml suspension sig: fifteen (15) ml po tid (3 times a day) as needed for heartburn. 19. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 20. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for wheezing. 21. insulin humalog insulin sliding scale 22. lorazepam 1 mg tablet sig: 1-2 tablets po once a day as needed for anxiety. 23. dexamethasone 4 mg tablet sig: 2.5 tablets po daily (daily): taper as follows: 10mg x 3 days, then 7.5mg x 4 days, then 5mg x 4 days, then 2.5mg x 4 days, then off, unless otherwise by md. 24. chlorambucil 2 mg tablet sig: two (2) tablet po once a day. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary diagnosis: lymphadenopathy causing tracheal obstruction secondary diagnosis: cll cad chf cri htn hyperlipidemia dm type ii hypothyroidism atrial fibrillation discharge condition: good, stable discharge instructions: you were admitted with fever and jaw pain. a ct scan was done which showed tracheal obstruction from buildup of lymph nodes in your chest and neck. this was making it difficult for you to breathe. as a result, you were electively intubated to protect your airway, and you then underwent radiation to this area to shrink the tumor. this worked quite well and your obstruction quickly resolved. you were exxtubated without problem and will continue to receieve radiation as an outpatient. you briefly needed a nasogastric tube to help you eat since the swelling in your mouth was so bad, but once it improved, our speech and swallow team decided that you could eat safely on your own. while intubated in our icu, you developed a fever and completed a course of antibiotics for a presumed pneumonia. you also had evidence of bacteria in your urine. however, since you were asymptomatic from this (no urinary burning/pain/frquency), we did not treat this bacteria. if you do develop these symptoms please contact your doctor. you also finished a course of fluconazole, an antifungal drug, for some thrush that you developed in your mouth, likely from your steroid medication. you did develop a superficial blood clot in your right arm, where you had a special kind of catheter called a picc line. we removed the line and applied warm compresses to the area. you do not need to be on an anticoagulation drug for this type of clot. you also develped swellling in your left arm, where your current picc is. we did an ultrasound and it showed no clot there. your heart also developed an abnormal rhythm called atrial fibrillation. this is normally a condition that requires anticoagulation, but given your low level of platelets and risk for bleeding, you cannnot have any anticoagulation. we called our cardiologists and they recommended management with a beta blocker called carvedilol, which you should take as prescribed. . please keep all of your outpatient appointments. please take all of your medicines as prescribed. if you develop any symptoms which concern you, such as fevers/chills, bleeding, or breathing difficulty, please call your doctor or go to the er. followup instructions: please keep the following appointments: provider: , md phone: date/time: 1:30 provider: , md phone: date/time: 1:30 provider: phone: date/time: 9:00 . please make an appointment to see your pcp: , . procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances biopsy of bone marrow biopsy of lymphatic structure other radiotherapeutic procedure diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified anemia, unspecified urinary tract infection, site not specified acute kidney failure, unspecified unspecified acquired hypothyroidism gout, unspecified atrial fibrillation candidiasis of mouth chronic kidney disease, unspecified acute respiratory failure diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled hyperosmolality and/or hypernatremia other and unspecified complications of medical care, not elsewhere classified chronic lymphoid leukemia, without mention of having achieved remission other diseases of trachea and bronchus hypertensive chronic kidney disease, malignant, with chronic kidney disease stage i through stage iv, or unspecified lymphosarcoma, lymph nodes of head, face, and neck 

Answer: The patient is high likely exposed to