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: prochlorperazine attending: chief complaint: admitted from dialysis unit with fever and ms changes major surgical or invasive procedure: 1. right groin dialysis catheter removal 2. right subclavian central line placement 3. left ej dialysis catheter placement history of present illness: 38 yr old female with h/o dm type i complicated by esrd s/p failed renal tx in , now on hd mwf, h/o cva in and with vp shunt initially that was removed infection, h/o mrsa and vre who was admitted from dialysis with septic picture and gram negative rod bacteremia. patient had fever to 105, rigors in hd. vancomycin 1g iv given. on arrival to ed temp 102.8, tachy to 120s, bp 160s/80s, rr 33, o2 95%2l. progressively more hypotensive in ed to sbp 90 -> put on levophed. given zosyn 3g, tylenol, ns 1l total, 2 mg ativan x 2 for right subclavian central line placement. patient was confused, unable to give hx or ros but responsive. she was transferred to the micu under the sepsis protocol. she was hypotensive and was aggressively fluid resuscitated and given one unit of blood with appropriate hct bump, but also required levophed to keep sbp >90. she came off pressors in early am. lisinopril and metoprolol were held. she was on an insulin gtt for tight glycemic control. blood cultures from initially grew out pan sensitive gnr ( bottles), and the patient was placed on zosyn in addition to the ceftriaxone that had been started in the ed. a tte was done to r/o vegetations and was negative. she improved clinically and was transferred to the general medicine floor the evening of . she remained afebrile, her white count trended down, and her surveillance blood cultures remained negative. past medical history: 1. esrd due secondary to diabetes, on hemodialysis three times weekly. she had a failed renal transplant () 2. diabetes mellitus type i with retinopathy, nephropathy and peripheral vascular disease, diagnosed as a child, brittle 3. cva (, ) with hydrocephalus status post vp shunt (removed in as csf grew out coag negative staph), right basal ganglia hemorrhage 4. hypercholesterolemia 5. hypertension 6. unclear history of grand mal seizure during dialysis 7. mrsa line tip infection with right atrial thrombus (line tip pulled ) 8. diffuse lymphadenopathy of unknown etiology. 9. chronically elevated alkaline phophatase 10. history of naphthelene induced coma from inhaling moth balls 11. recently admitted with fever of unknown origin - culture grew vre bacteremia (completed linezolid in 11/). past surgical history 1. status post failed renal transplant in 2. status post parathyroidectomy 3. status post multiple amputations (right bka, left digit, left metatarsal) 4. exploratory laparotomy and appendectomy for appendicitis in 5. prior history of tracheostomy social history: ms usually lives in jp with her daughter and granddaughter, although she came from rehab. her sister-in-law, , helps her with management of her multiple medications. no tobacco or alcohol use. her baseline is such that she can feed herself, knows when to take medicines and when to go to dialysis. family history: family history of diabetes mellitus in children. physical exam: temp: 96.6 bp 139/76 hr:97 rr:22 100%o2 sat general: confused, pleasant, oriented x 2(person and place) but not time (thought it was "" and did not know month), able to follow one-step commands, ill-appearing heent: nc, well healed scar in left frontal lobe, perlla, mmm, op clear, no lesions, no pharyngeal edema, exudate neck: non-tender, shoddy lad, no thyromegaly, no jvd, surgical scar at neck chest: right subclavian line w/o signs of infeciton heart: regular, normal s1 and s2, no m/r/g lung: cta bilaterally abd: + bs, soft, multiple scars, non-tender, distended, tender right groin lad sacrum: grade sacral decub, no discharge, non-tender, clean base, granulation tissue extr: left mt amputation, right bka, no edema neuro: alert and oriented to person and place, but not time. appropriate. no focal neurological deficits appreciated. pertinent results: admission: 07:20pm blood wbc-36.4*# rbc-3.53* hgb-9.7* hct-33.0* mcv-93 mch-27.5 mchc-29.5* rdw-16.5* plt ct-687* 07:20pm blood neuts-89* bands-5 lymphs-2* monos-2 eos-0 baso-0 atyps-0 metas-2* myelos-0 07:20pm blood glucose-197* urean-20 creat-4.4*# na-135 k-4.3 cl-94* hco3-25 angap-20 07:20pm blood ck-mb-notdone ctropnt-0.94* 03:41am blood ck-mb-notdone ctropnt-0.84* 07:20pm blood alt-15 ast-28 ck(cpk)-21* amylase-74 totbili-0.5 03:41am blood ck(cpk)-70 10:12pm blood ld(ldh)-211 07:20pm blood calcium-9.7 mg-1.5* 07:15pm blood lactate-3.8* 03:41am blood vanco-6.7* 10:12pm blood cortsol-25.5* 01:00am blood cortsol-34.8* micro data: blood cultures: 6/6 bottles citrobacter koseri resistant to piperacillin neg neg neg neg perma cath culture: >15 colonies citrobacter koseri r to piperacillin c diff: negative cxr : no acute pulmonary disease. echo : 1. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. 2. the aortic valve leaflets are mildly thickened. 3. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 4. no evidence of endocarditis seen. 5. compared with the findings of the prior study of , there has been no significant change. left subclavian tunnelled line placement (), revised (). impression: successful exchange of existing triple-lumen catheter for a dual-lumen dialysis catheter with tip in the high right atrium. the catheter tip-to-cuff length measures 23 cm. catheter is ready for immediate use. brief hospital course: 38f with multiple medical problems including dm i, esrd s/p failed renal tx, now on hd, h/o cvas and hydrocephalus presented with line sepsis from right groin hemodialysis line. 1. id sepsis: the patient was admitted with fevers (to 105) and change in mental status. the sepsis protocol was initiated and the patient was transferred to the micu, she was placed on antibiotics, aggressively fluid hydrated and briefly on levophed; she was given a unit of prbcs with an appropriate hct bump. the source was thought to be her right groin dialysis line and this was removed and sent for culture. her blood cultures and catheter tip from admission initially grew out pan sensitive gram negative rods, that were then further speciated into citrobacter koseri resistant to piperacillin. initially she had been given a dose of vanco at hemodialysis, then started on ceftriaxone in the ed; zosyn was added with initial cx data for broader coverage; finally she was switched to levofloxacin, renally dosed to complete a 14 day course. her surveillance cultures were negative after antibiotics were initiated. she did not spike >101 for the remainder of her stay. the patient also had a chronic decubitus ulcer which did not appear necrotic. a wound care consult was obtained and recommended duoderm dressings and a special mattress. during her hospitalization, two areas of skin breakdown were noted in her right groin at the site of her previous dialysis catheter. there was no fluctulance, and these were kept clean and dry. additionally, the patient has abdominal fluid collections from her vp shunt that cannot be fully drained and have grown coag negative staph in the past. 2. neuro the patient has a history of cvas and briefly had a vp shunt for hydrocephalus (it was removed infection in ); she presented with mental status changes from her baseline likely in context of her sepsis. this was clearing slowly as her infection was treated and as she re-initiated hemodialysis. while hospitalized her ambien was held, but her oxycodone was continued as she required it for pain. 3. gi the patient began to have diarrhea during her hospitalization. her outpatient reglan was held. c. difficile was checked x2 and was negative. she was then started on immodium. the patient was continued on her protonix. she has csf collections in her abdomen at baseline vp shunt (see previous dc summary for additional details). 4. renal the patient has long standing end stage renal disease secondary to her diabetes and is anuric at baseline on hemodialysis mwf. she had a right groin tunnelled line on admission that was discontinued and likely the cause of her sepsis. once she had been afebrile and on antibiotics, with negative surveillance cx, another tunnelled line was placed in the left subclavian by ir; this line had to be changed (same site) as it was not large enough for hd. she was able to undergo hemodialysis on . she was continued on her renagel and her electrolytes were monitored as below. renal followed her throughout her course. 5. endo the patient had a long standing history of type i dm starting at age 4 complicated by retinopathy, nephropathy, and neuropathy requiring ue and le amputations. at home she is on lantus 12 units. she was placed on an insulin gtt while in the micu for tight glycemic control and was transitioned to a riss and lantus 12 units qhs (outpatient dose) on transfer to the floor. a consult was obtained for bg >300 on the floor. her lantus was titrated up to 20 qhs and she became somewhat hypoglycemic the following day (low fs 38). she was given a total of 2 amps d50 and started on d5 1/2ns at 50/hr. her lantus was decreased to 15 units qhs, then to 13 units qhs and her fingersticks were adequately controlled thereafter. she was discharged to rehab on her usual outpatient dose of lantus and a regular insulin sliding scale. 6. heme the patient has a history of anemia with baseline hcts in the mid-high 20s. on admission her hct was 33 and fell to 27.5 and she was transfused 1 unit prbcs with hct bump to 31. her hematocrit was stable throughout the rest of her course. she had some bleeding around her new hemodialysis catheter site which was controlled with a pressure dressing and did not require ddavp. on admission the patient had an inr of 3.1 and ptt 150. her platelets, ldh, and total bili were normal, and her coagulopathy resolved with treatment of the sepsis. 7. cv ischemia: initially the patient had a mild troponin leak (peak 0.94) likely in setting of sepsis, cks <100. no ekg changes. pump: the patient is hypertensive at baseline on lisinopril and metoprolol, but became hypotensive in the setting of sepsis, requiring levophed and ivf hydration. her antihypertensive medications were initially held and lisinopril was added back once she was on the floor, followed by metoprolol. she was discharged on her regular outpatient doses. rate/rhythm: the patient was initially tachycardic, and once she was volume repleted and treated for sepsis, returned to nsr without ectopy. 8. fen: after transfer out of the micu, she was maintained on a renal/diabetic diet and b complex/vitamin c/zinc. she required kayexalate while she was waiting for hd for an elevated potassium. 9. proph: the patient was maintained on hep sq and was tolerating a renal/diabetic diet while on the floor, she had freq turns given her decubitus ulcer and was seen by wound care consult, she was kept on her oxycodone 5-10mg q4-6 hrs per outpatient regimen, her bowel regimen was held given the diarrhea and once her c diff came back negative x2 she was started on immodium. 10. the patient was full code. 11. communication: the patient's hcp is , . she was aware of the patient's hospitalization and course. 12. access: the patient initially had a right subclavian triple lumen; this was removed and a new tunnelled catheter was placed in her left subclavian on for hemodialysis. 14. precautions: vre and mrsa 15. the patient was discharged to . medications on admission: 1. lisinopril 20 mg po qd 2. fluoxetene hcl 10 mg po bid 3. vit c 500 mg tid 4. b-complex with vit c 5. zinc sulfate 220 mg po qd 6. amlodipine besylate 10 mg po qd 7. reglan 8. lantus 12 units qhs 9. metoprolol 100mg daily 10. oxycodone 5-10mg q4-6 hrs prn 11. subq heparin 5000 units tid 12. renagel 600mg tid 13. pantoprazole 14. ambien 5mg qhs 15. aspirin 81mg daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for diarrhea. 3. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection q8h (every 8 hours). 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. fluoxetine hcl 10 mg capsule sig: one (1) capsule po bid (2 times a day). 7. oxycodone hcl 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 8. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. sevelamer hcl 800 mg tablet sig: one (1) tablet po tid (3 times a day). 11. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily) as needed for dm i. 12. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 10 days. 13. insulin glargine 100 unit/ml solution sig: twelve (12) units subcutaneous at bedtime. 14. insulin regular human 300 unit/3 ml syringe sig: per insulin sliding scale subcutaneous four times a day: qid fingerstick. 15. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day: hold for hr < 60, sbp < 100. 16. loperamide hcl 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed. 17. ambien 5 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia: hold for sedation, confusion. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis 1. gram negative rod sepsis (citrobacter koseri) secondary to infected dialysis catheter secondary diagnoses 2. end stage renal disease on hemodialysis mwf 3. diabetes mellitus type i complicated by retinopathy, nephropathy, and peripheral neuropathy s/p multiple amputations 4. multiple cvas h/o vp shunt placement, removed infection 5. mrsa and vre discharge condition: stable discharge instructions: please take all your medications as prescribed. call your doctor or return to the emergency department if you notice fevers, chills, night sweats, worsening confusion, nausea, vomiting, chest pain, difficultly breathing, or any other symptoms concerning to you, your caretakers, or your family. followup instructions: please follow up with dr. in weeks after discharge. please continue to get your dialysis mondays, wednesdays and fridays. procedure: venous catheterization, not elsewhere classified hemodialysis venous catheterization for renal dialysis transfusion of packed cells infusion of vasopressor agent diagnoses: anemia in chronic kidney disease severe sepsis unspecified viral hepatitis c without hepatic coma hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease septic shock pressure ulcer, lower back infection and inflammatory reaction due to other vascular device, implant, and graft septicemia due to anaerobes other and unspecified coagulation defects complications of transplanted kidney diabetes with renal manifestations, type i [juvenile type], not stated as uncontrolled 

Answer: The patient is high likely exposed to