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: patient recorded as having no known allergies to drugs attending: chief complaint: fever and hypotension. major surgical or invasive procedure: status post skin biopsy of left scapular region status post placement of hickman catheter status post insertion and removal of right internal jugular central venous catheter. status post insertion and removal of right arm midline history of present illness: full code nkda cc: 54 yo with mds (requiring prbc qowk, plt transfusion in the several weeks perceding admission; bmbx w/ increased blasts (23% on aspirate)) who presents to clinic w/ 2days of fever (t102), chills. recently completed 4 wk course of augmentin for l thigh folliculitis. ros +diarrhea. in clinic found to be in af rvr 150-160s w/ sbp70's responsive to fluid bolus x1. initial labs showed wbc 0.2 (0 pmn). past medical history: pmh: myelodysplastic syndrome hypertension remote history of kidney stones social history: lives at home with wife. formerly employed in engineering/sales. lives with wife in . no children. no etoh no tobacco physical exam: physical examination on presentation, blood pressure 90/60, responded to one liter of fluids. heart rate 150 with regular rate. temperature 101.5. a well-developed, well-nourished male, acutely ill with shaking chills. o2 sat on room air are 98%. he is tachypneic. heent, sclerae are anicteric pupils equal and reactive to light. mouth, there are no oral lesions. lungs, clear. heart, tachypneic, regular rate. abdomen, nontender. spleen tip at the left sternal border. bowel sounds are present, no rebound. extremities, lower extremity petechiae. no cyanosis, clubbing or edema. pertinent results: 9:50 am blood culture **final report ** aerobic bottle (final ): enterobacter cloacae. identification and sensitivities performed on culture # 172-7782s (). anaerobic bottle (final ): enterobacter cloacae. identification and sensitivities performed on culture # 172-7782s (). 8:40 am blood culture **final report ** aerobic bottle (final ): reported by phone to , -7f- @ 20:20 . enterobacter cloacae. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s gentamicin------------ <=1 s levofloxacin----------<=0.25 s meropenem-------------<=0.25 s piperacillin---------- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s anaerobic bottle (final ): enterobacter cloacae. identification and sensitivities performed from aerobic bottle. 7:35 am urine/serology **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. ----------------- 9:30 am sputum site: induced gram stain (final ): <10 pmns and >10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and chains. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): heavy growth oropharyngeal flora. immunofluorescent test for pneumocystis carinii (final ): pneumocystis carinii not seen. nocardia culture (preliminary): no nocardia isolated. fungal culture (preliminary): no fungus isolated. potassium hydroxide preparation (final ): ordered . no fungal elements seen. radiology final report ct chest w/o contrast 4:11 pm ct chest w/o contrast impression: 1) no significant interval change in extensive, ill-defined, diffuse nodular and patchy opacities which are predominantly distributed within both upper lobes. these findings in this neutropenic patient are most suggestive of an infectious etiology with invasive aspergillosis high on the differential. the radiographic differential diagnosis also includes other fungal infections, pcp, emboli, cryptogenic organizing pneumonitis, and less likely, vasculitis. 2) stable mediastinal lymphadenopathy. 3) small bilateral pleural effusions, slightly decreased in size since the prior study. 4) tiny non-obstructing right renal calculus. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sat 2:23 pm cardiology report echo study date of conclusions: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. the ascending aorta is moderately dilated. 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 mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (tape reviewed) of , there is no significant change. no vegetations seen (but cannot exclude). electronically signed by , md on 19:14. physician: , . radiology final report ct abd w&w/o c 11:57 am ct abd w&w/o c; ct pelvis w/contrast impression: 1) small bilateral pleural effusions and bibasilar infiltrates/opacities. 2) small right renal stone without obstruction. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 3:13 pm radiology final report ruq ultrasound: the gallbladder is unremarkable without evidence of stones, sludge, or gallbladder wall edema. there is no intrahepatic or extrahepatic biliary ductal dilatation. the common bile duct is normal in size, measuring 3 mm. son sign was not ellicited. impression: unremarkable right upper quadrant ultrasound. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sun 9:11 am -------------------- radiology final report ct chest w/o contrast 10:17 am impression: 1. multiple, ill-defined, irregularly marginated pulmonary nodules throughout both lungs, predominantly within both upper lobes, which have not significantly changed since the prior study. these findings, again, are most suggestive of an infectious etiology. the diffuse distribution of these lesions less likely favors emboli. 2. continued bibasilar atelectasis/consolidation with small bilateral pleural effusions, not significantly changed in size since the prior study. 3. stable mediastinal lymphadenopathy. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sun 9:11 am , pathology examination diagnosis: skin, left back, punch biopsy: superficial and mid-dermal perivascular lymphocytic infiltrate with upper dermal red blood cell extravasation (see note.) note: no atypical cells or granulomatous inflammation is seen. a single microscopic aggregate of neutrophils is focally noted in the papillary dermis. special stains for bacteria (brown and brenn) and fungi (pas) are negative. the infiltrate is pauci-inflammatory and nonspecific, raising the possibilities of a systemic hypersensitivity reaction or reaction to treatment. clinical correlation is recommended. if clinical concern for a infection disseminated to the skin persists, biopsy of another lesion may be further informative. cardiology report echo study date of conclusions: 1.the left atrium is moderately dilated 2.the left atrium is elongated. left ventricular wall thicknesses are normal. the ventricular cavity size is normal. there is normal left ventricular function.. 3. right ventricular chamber size is normal. there is possible mild global right ventricular free wall hypokinesis. 4.the ascending aorta is mildly dilated. 5.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6.the mitral valve appears structurally normal with trivial mitral regurgitation. 7.there is no pericardial effusion. electronically signed by , md on 22:14. physician: , . () radiology final report us extremity nonvascular left 4:36 pm us extremity nonvascular left reason: pt with red hot area on lue, r/o abscess medical condition: 54 year old man with neutropenia, fever, cellulitis. please evaluate cellulitis on left arm for abscess. reason for this examination: r/o abscess indication: neutropenia, fever, cellulitis. rule out abscess. limited left upper extremity ultrasound: imaging of the left upper extremity in the area of erythema and swelling shows no evidence of fluid collections to indicate an abscess. there is edema of the soft tissues. impression: no abnormal fluid collections to indicate an abscess identified. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 11:30 pm ------------------- radiology final report cta chest w&w/o c &recons 7:27 pm; ct 150cc nonionic contrast reason: eval for pna, pe, chf contrast: optiray impression: 1. suboptimal visualization of the pulmonary arterial segmental and subsegmental levels. however, no pulmonary embolism is identified within the main pulmonary arterial trunk and main branches. 2. multiple diffuse bilateral pulmonary nodules, predominantly within the upper lobes, which given the patient's immunocompromised state are most concerning for an infectious process such as fungal disease. emboli, metastatic disease, and pulmonary edema are much less likely considered in the differential. 3. bibasilar atelectasis/consolidation with small bilateral pleural effusions, right greater than left. 4. mediastinal lymphadenopathy. the study and the report were reviewed by the staff radiologist. dr. dr. approved: mon 8:20 am 04:20pm ld(ldh)-194 ck(cpk)-137 04:20pm ck-mb-2 ctropnt-<0.01 04:20pm phosphate-1.7* 08:40am glucose-131* urea n-18 creat-1.5* sodium-134 potassium-3.7 chloride-98 total co2-23 anion gap-17 08:40am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 08:40am urine hemosid-negative brief hospital course: mr. was admitted to bmt and started on cefipime, vanco, and lvq x1 dose (changed to cipro 400iv on ). aerobic and anaerobic bcx from grew out gnr enterobacter cloacae(pan sensitive) and ucx w/ gnr and enterobacter. admitted to icu after repeat episode of af rvr (130-150) w/ bp 90's, 90% 2l, placed on 100% nrb w/ spo2 hi 90's; following 1l bolus--> sbp 100's. hct 20.8 (from 25 in am) w/ new ha--> nchct w/o evidence of ich. cvl placed, then removed ~2wks later secondary to persistant fevers and a concern for it as a source of infection abx start dates: 1. id: febrile neutropenia a.urosepsis with + and +blood cultures for enterobacter now negative x many days. gnr (enterobacter) on bcx. ucx that day enterobacter and diptheriods. bcx enterobacter pansensitive. abx were switched to ciprofloxacin and meripenem providing double coverage for gram (-) organisms. tte did not show valvular lesions. labs showed elevated d-dimer at 2257, but also elevated haptoglobin at 396, fibrinonogen 430, suggesting generalized inflammation without dic. b.multiple diffuse bilateral pulmonary nodules, predominantly within the upper lobes, most concerning for an infectious process such as fungal disease, but also may be c/w gnr emboli. sputum and repeat chest ct's did not offer putative etiology. required non-rebreather for a number of days in icu, but eventually weaned to 8 l nasal canulae and over the course of 2 weeks, to room air; his oxygen saturation at discharge was 95% on ra. a tte on showed no valvular lesions. an abdominal ct to assess for hepatic infection was normal. repeat chest cts have shown no change in the pulmonary nodules, but resolving effusion and resolving lymphadenopathy. induced sputum with gram stain showed heavy growth of oropharyngeal flora, (-)prelim nocardia cx, (-)pcp , (-)prelim fungal cx, (-)fungal koh prep. c.folliculitis: derm biopsy of follicular plaque on back. gram stain: no pmns, no microorgranism. no fungus. no afb. nocardia cx negative. enterobacter cloacae isolated. per derm unlikely lymphoma cutis. most likely hypersensitivity to infxn c gnrs, ecthyma gangrenosum, sweet's syndrome, or medications. has been regressing on antibiotics. d.cellulitis on left upper arm/shoulder. despite regressing over during the course of antibiotics, the region displayed some fluctuance on exam. an ultrasound exam was negative, and the regional infection was considered by the medical and infectious disease teams to be well sequested. e. the right internal jugular central venous line was pulled, but fevers persisted, and the catheter tip yielded no significant growth. f. persistent fevers: although mr. showed marked clinical improvement over the course of admission, he remained febrile. danazol, neupogen, and vancomycin were discontinued as potential causes of medication-induced fever, considering that meropenem was providing adequate gram positive coverage. after multiple sources were ruled out (endocarditis, medications, line infection, etc.),he was started on low dose steriods, prednisone 10 mg qd, with resolution of fevers. it was felt that underlying myelodysplastic syndrome may be a source of his persistent fever. the patient was therefore discharged to home in good condition on prednisone 10mg qd, tylenol 500mg qd, ciprofloxacin 500mg , caspofungin 35 mg qd, meropenem 2000mg in addition to the other listed medications. caspofungin was used after ambisome resulted in a conjugated bilirubinemia and voriconazole resulted in elevation of transaminase levels. 2. pulm: mr. pulmonary infection was compounded by a component of chf. the pulmonary infectious workup is listed as above in infectious disease section. with a lasix diuresis, his pleural effusions, 3+ pitting leg edema to the thighs, and positive fluid balance all corrected. 3. heme-onc: mds w/ pancytopenia (hct 26-28 baseline) increased blasts on bmbx (none in periphery) on danazol, aransep, desyrel (ferritin >); receiving prbc qowk, plt transfusions intermittently in last several months. received transfusions to keep hct >25 and plts >10 (>50 if bleeding). 4. gi: the initial course of ambisome resulted in an elevated direct bilirubin level. ruq u/s and abdominal ct without liver lesions/obstruction. was then started on voriconazole until liver transaminases trended up. now on caspofungin with liver enzymes trending down towards normal. 5. a fib with rvr: likely bactermia (ruled out for mi, nl tsh), resolved after dilt 20 iv x 2, then dilt po 30 qid. dilt d/c on and on low dose metoprolol. in sinus rhythm. 6. htn: on meds at home with baseline bps in 100s per patient. in hospital, on metoprolol but transitioned back to home medications on discharge. leg cuff bp's because l arm cellulitis, r arm midline. 8. renal/f/e/n: small renal stone in pole of r kidney fluids were d/c on as pt looks like in pulm edema (with lower extremity edema). given lasix 40 mg iv qd and then prn for diuresis. 9. diabetes: no abnormal fsbgs. 10. prophylaxis: pepcid and pneumoboots. serax for sleep 11. access: surgery placed r internal jugular cvl . transfused platelets for above 50k for line to be placed. right midline placed after right ij d/c'd secondary to ?fever source. double-lumen hickman placed by surgery before discharge but visualized by pa/lat to be in l brachiocephalic. pulled by surgery on day of d/c after platelets given pre-procedure. will arrange as outpatient to obtain hickman, although may return as inpatient for one night to give blood or plt transfusion. 12. disposition: to home in stable condition on antibiotics, tylenol, and prednisone 10 mg qd. antibiotics will be discontinued based on radiologic resolution of the pulmonary and dermatologic conditions. will receive visiting nursing to set up with home infusions of antibiotics. medications on admission: atenolol 12.5 mg qd danazol 200 mg p.o. t.i.d. aranesp 200 mg subcu q. weekly nexium 40 mg daily. discharge medications: intravenous treatments/medications meropenem mg iv bid caspofungin 35 mg iv once daily other medications ciprofloxacin 500 mg po bid atenolol 12.5 mg po qd esomeprazole 40 mg po qd neutra-phos 1 packet tid prn low ph; will be directed further in clinic. tylenol 500 mg po each day at 6pm prednisone 10 mg po each daily serax 10 mg po qhs prn insomnia discharge disposition: home discharge diagnosis: myelodysplastic syndrome enterobacter cloacae bacteremia pulmonary and skin nodules consistent with infectious etiology cellulitis discharge condition: stable. discharge instructions: please call your physician if you have shortness of breath, difficulty breathing, lightheadedness, worsening skin infection, bleeding, or fevers. please take antibiotics, including iv and oral according to the prescriptions. a visiting healthcare agency will help you set up the iv medications. followup instructions: provider: , md where: hematology/bmt phone: date/time: 1:30 procedure: venous catheterization, not elsewhere classified transfusion of packed cells other incision of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue transfusion of platelets diagnoses: pneumonia, organism unspecified sepsis cellulitis and abscess of upper arm and forearm septicemia due to anaerobes other and unspecified mycoses other specified diseases of hair and hair follicles other pyoderma 

Answer: The patient is high likely exposed to