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 / ceftriaxone / strawberry / bleach attending: chief complaint: groin abcess, hypotension major surgical or invasive procedure: ercp with stent placement ir procedure(percutaneous cholecystostomy tube placement) history of present illness: 65f w/ iddm, esrd, morbid obesity, and history of multiple line infections who recently had an i&d of a groin abscess on . she presented to the ed today after undergoing hd at per repacking of her abscess but was found to be hypotensive w/ sbps in the 80s. ms. reports recent nausea and vomiting related to her abx (doxy and bactrim). she reports an undocumented fever past wednesday but none since. she has had a productive cough since yesterday with yellowish-brown sputum. she denies any cp, myalgias, pain. per the abscess she has been to the ed twice for dressing and reports improvement. she has a history of constipation and last moved her bowels a few days ago. she has some abdominal discomfort in that she feels bloated, and has localized ttp in the llq. no recent dx of diarrhea. in the ed, patient became hypotensive to 80/40, subjectively feels "not right" but no reports of dizziness (no change in symptoms from presentation). given 250cc bolus of ns x 2. however, she was not felt to be fluid responsive and was started on levophed and central line was placed. also labs came back acidotic with bicarb of 11, repeat 15 on green top. her ekg demonstrated junctional rhythm at 62 bpms, lad, ni, consistent with prior. she had a normal lactate. was given cipro, flagyl,. ct abdomen and cxr were "unremarkable". she recieved a total of 2l in ed. . in the micu, she was vitally stable on a levophed drip. . review of sytems: (+) per hpi, + llq pain, constipation with last bm 3 days prior (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied shortness of breath. denied chest pain or tightness, palpitations. denied diarrhea. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: - atrial tachycardia: seen by dr. in and felt to be atrial tachy illness, no indication for ablation - hemorrhagic pericardial effusion - bilateral internal jugular thromboses, restarted on coumadin - h/o bilateral lower extremity dvt's - esrd on hd t, th, sat - iddm - diastolic heart failure - pulmonary hypertension - hypercholesterolemia - osa, noncompliant with cpap as outpatient (on 2l home o2) - oa - h/o c. diff - gerd - depression - morbid obesity - fibroid uterus; vaginal bleeding - h/o osteomyelitis at the t9 vertebrae ; tx with vanc - h/o multiple line infections . micro hx: **: providencia, treated with 4 wk course of aztreonam **: staph coag positive, sensitive to both vancomycin and gentamicin **: staph bacteremia tx with vanc x 6 weeks **: proteius mirabilis and mssa, treated with ceftaz and vanc social history: patient denies tobacco, alcohol or illicit drug use. she lives in a nursing home () since the last 4 years. she is separated from her husband. she has 5 children in area. family history: two children with asthma. otherwise non-contributory. physical exam: on admission: vitals: t: 99.4/37.4 bp: 86/58 p: 81 r:17 o2: 100% on 3l nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley - well healing abscess ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema neuro: a&ox3, cnii-xii intact, sensation and strength grossly intact in all extremities discharge exam: vs - temp 98.5 f, 83 hr , 15 rr , 116/42 bp , 99 o2-sat % 2l general - obese woman nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - diminished breath sounds bilat, no r/rh/wh, poor air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/obese, ttp in ruq with deep palpation, no masses or hsm, no rebound/guarding, +bs extremities - wwp, no c/c, mild 1+ edema, 2+ peripheral pulses (radials, dps), l sided femoral tunnelled dialysis catheter in place cdi skin - numerous sc calcifications in b/l le lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ pertinent results: =================== laboratory results =================== on admission: wbc-7.1 rbc-3.55* hgb-11.8* hct-40.0 mcv-113* rdw-14.0 plt ct-327 --neuts-79.4* lymphs-14.6* monos-3.9 eos-1.8 baso-0.3 pt-34.1* ptt-34.3 inr(pt)-3.4* glucose-102* urean-17 creat-3.4*# na-137 k-6.0* cl-111* hco3-11* alt-23 ast-24 alkphos-174* totbili-0.2 lipase-58 calcium-9.9 phos-6.0*# mg-1.9 on discharge: 06:26am blood alt-14 ast-11 ld(ldh)-137 alkphos-164* totbili-0.2 06:26am blood glucose-111* urean-38* creat-7.0*# na-135 k-4.8 cl-97 hco3-29 angap-14 06:26am blood wbc-6.4 rbc-2.28* hgb-7.2* hct-24.3* mcv-107* mch-31.7 mchc-29.8* rdw-15.6* plt ct-337 ============= microbiology ============= blood culture * 3 : no growth urine culture : urine culture (final ): gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. gram negative rod(s). ~/ml. blood cultures 1/3 : blood culture, routine (final ): klebsiella pneumoniae. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . dr. () requests snesitivity testing to aztreonam , tetracycline and tigecycline . tigecycline = 2 mcg/ml = sensitive, tigecycline sensitivity testing performed by etest. aztreonam = resistant. aztreonam & tetracycline sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | amikacin-------------- 16 s ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- 8 s ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin/tazo----- i tetracycline---------- i tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r aerobic bottle gram stain (final ): reported to and read back by @ 1518 on - cc6d. gram negative rod(s). urine culture : urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- 16 r ceftriaxone----------- 8 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r catheter tip culture : no growth blood culture *3 : no growth bile culture : gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): escherichia coli. sparse growth. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- =>64 r ceftriaxone----------- 8 r ciprofloxacin--------- =>4 r gentamicin------------ 2 s meropenem-------------<=0.25 s tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r anaerobic culture (final ): no anaerobes isolated. blood culture * 4 : no growth ============== other studies ============== ecg : possible junctional rhythm. left anterior fascicular block. compared to the previous tracing p waves are no longer visible suggesting junctional rhythm. the other findings are similar. ct abdomen and pelvis with contrast : impression: 1. choledocholithiasis and stable dilated cbd to 12 mm. 2. no colonic diverticulitis. 3. fibroid uterus. ct chest w/contrast : impression: 1. enlarged pulmonary artery in keeping with pulmonary hypertension. moderate cardiomegaly. 2. small bilateral pleural effusions with overlying consolidation and atelectasis within the lower lobes bilaterally. 3. multinodular goiter with bilateral thyroid nodules. ct right lower extremity with contrast impression: 1. skin thickening and irregularity along the right inguinal fold at site ofprevious i&d. no evidence of abscess. 2. fibroid uterus. 3. moderate calcification of the common femoral, superficial femoral and profunda femoral arteries bilaterally. femoral line placement and ptc : impression: 1. exchange of the left femoral temporary hemodialysis catheter with a new 14 french, 24 cm temporary hemodialysis catheter. the line is ready for use. 2. placement of an 8 french internal-external biliary drainage catheter via a right posterior biliary duct with its retention pigtail loop in the duodenum. ercp: impression: a peri-ampullary diverticulum was present. a stent was seen extruding from the ampullary orifice - this corresponds to patient's known internal-external ptc drain. cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. contrast medium was injected resulting in complete opacification. a moderate diffuse dilation was seen at the biliary tree with the cbd measuring 15 mm. several filling defects were seen in the cbd consistent with stones. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. balloon sphincteroplasty was then performed with a wire-guided cre balloon and the ampulla/distal cbd was successfully dilated to 15 mm. several balloon sweeps were then performed with successful extraction of two 8 mm stones. as the bile duct was very large and complete opacificiation was not possible, it was unclear whether there were any retained stones. thus, a 5cm by 10fr dougle pigtail biliary stent was placed successfully. recommendations: npo overnight with aggressive iv hydration with lr at 200 cc/hr. follow for response and complications. if any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ercp fellow on call () further management of ptc drain as per ir. repeat ercp in 1 month for stent removal and complete duct clearance. pending studies: wound swab culture from . brief hospital course: 65 yo woman presenting from nursing facility with recent well-healing groin abcess, admitted with cholangitis, klebsiella bacteremia, septic shock, and hypercarbic respiratory failure. hospital course was also notable for deep venous thrombosis. #cholangitis/klebsiella bacteremia/septic shock/choledocholithiasis: patient was admitted to the medical intensive care unit in septic shock requiring vasopressor support and found to have klebsiella bacteremia. lfts were normal, but an abdominal ultrasound showed a dilated common bile duct. bedside ercp was unsuccessful but a percutaneous biliary drain was placed and the patient improved with drainage and antibiotics and was able to be taken off vasopressors. once the patient was hemodynamically stable a repeat ercp was performed which was notable for choledocholithiasis and a sphincterotomy with stone extraction was performed and a biliary stent was placed. patient completed a 2 week course of meropenem prior to discharge. patient will return for stent removal in one month from discharge. #hypercarbic respiratory failure/obstructive sleep apnea: this was felt to be related to the patient's sepsis. she was intubated and then extubated when sepsis improved. following treatment of her infection she was maintained on l oxygen by nasal canula. following second ercp the patient did require transfer to icu as anesthesia did not feeel comfortable extubating patient immediately after the procedure. she was extubated without incident however. she has obstructive sleep apnea and was instructed to wear her bipap at night once discharged. #lower extremity deep venous thrombosis/end stage renal disease on hemodialysis: patient was found to have left lower extremity dvt in the same leg as her femoral hemodialysis line. given the patient's problems with access in the past, the decision after discussion with nephrology was to keep the line in and continue anticoagulation. since coumadin was held for the patient's ercp, the patient required a heparin gtt bridge to coumadin until inr was therapeutic at goal . this will be followed by providers at patient's extended care facility. #groin abcess: the patient has a groin abcess, looked well healed. wound care was consulted and followed the patient. on day of discharge there was pus noted from around the hemodialysis line. renal was made aware and cultures were taken but the renal team did not want to start empiric antibiotics. the cultures will be followed by outpatient nephrology and antibiotics started as indicated. # pruritis: upon transfer to the prior to second ercp, ms. began to note pruritis of her back. there existed a maculopapular rash on the regions of her back which contact her sheets. she remembers an allergy to bleach. her pruritis improved with discontinuation of bleached sheets, sarna lotion, and a short course of topical clobetasol. she also was placed on miconazole power for fungal groin rash. . #depression: paxil was continued. #gerd: ppi was continued. #hx of atrial tach: amiodarone was continued. #diabetes mellitus type 2: continued home nph and iss transitional issues: - patient is having intermittent vaginal bleeding, she should be evaluated by gyn as an outpatient for possible endometrial biopsy - patient's left tunneled line was noted to have mild possibly purulent discharge at dialysis on . cultures were obtained and will need follow up. there were however no other symptoms or signs of infection. medications on admission: 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. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. b complex vitamins capsule sig: one (1) cap po daily (daily). 5. bactrim ds 800-160 mg tablet sig: two (2) tablet po at hd. 6. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 7. duoneb 0.5-2.5 mg/3 ml solution for nebulization sig: one (1) nebulizer inhalation q8h:prn as needed for shortness of breath or wheezing. 8. folic acid 1 mg tablet sig: two (2) tablet po once a day. 9. insulin please continue your previous insulin regimen of nph 20 units qam and novolog ss. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 11. paroxetine hcl 20 mg tablet sig: 1.5 tablets po daily (daily). 12. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 13. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 14. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 15. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. 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. folic acid 1 mg tablet sig: two (2) tablet po daily (daily). 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for wheezing. 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 6. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 7. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. amiodarone 200 mg tablet sig: one (1) tablet po once a day. 12. outpatient lab work please check daily inr and cbc on to ensure that patient is therapeutic on warfarin and that hct is not downtrending (last hct on discharge was 24.3). 13. nph insulin human recomb 100 unit/ml suspension sig: twenty (20) subcutaneous qam. 14. insulin lispro 100 unit/ml solution sig: as directed by sliding scale subcutaneous asdir (as directed). 15. acetaminophen 325 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for pain/fever. 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 17. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). 18. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 19. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed for itching. 20. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 21. diphenhydramine hcl 12.5 mg/5 ml elixir sig: one (1) po q8h (every 8 hours) as needed for itching. 22. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for pruritus. 23. coumadin 1 mg tablet sig: five (5) tablet po once a day. discharge disposition: extended care facility: - discharge diagnosis: 1. cholangitis 2. respiratory failure 3. diabetes mellitus 4. end stage renal disease requiring dialysis 5. dvt 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: dear ms. , it was a pleasure taking care of you at . you were admitted with a severe bacterial infection because of an obstruction of your bile ducts(cholangitis). you had a biliary drain(cholecystostomy) placed by interventional radiology to drain infected bile, but the drain was removed after a few days when you had the ercp procedure. during the ercp procedure, a stent was placed in your bile duct. the following changes have been made to your medications: start warfarin for the clot in your leg (duration to be determined by your primary care physician) start benadryl as needed for itching start nephrocaps for nutrition start sarna lotion as needed for itching start miconazole as needed for itching or skin-based yeast infections please make sure inr is checked on dialysis days for next two weeks to ensure that it is in therapeutic range. followup instructions: 1. you will be admitted to a medical acute care facility where a physician will continue to follow your care. 2. the gastroenterology department will be scheduling a follow up procedure(ercp) and will contact you with the date/time. department: transplant center when: monday at 9:20 am with: , md building: lm campus: west best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other endoscopy of small intestine hemodialysis venous catheterization for renal dialysis endoscopic removal of stone(s) from biliary tract endoscopic sphincterotomy and papillotomy endoscopic dilation of ampulla and biliary duct endoscopic insertion of stent (tube) into bile duct removal of t-tube, other bile duct tube, or liver tube other percutaneous procedures on biliary tract central venous catheter placement with guidance diagnoses: acidosis hyperpotassemia end stage renal disease obstructive sleep apnea (adult)(pediatric) renal dialysis status pure hypercholesterolemia urinary tract infection, site not specified congestive heart failure, unspecified severe sepsis acute respiratory failure long-term (current) use of insulin septic shock paralytic ileus other septicemia due to gram-negative organisms diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled cholangitis chronic diastolic heart failure calculus of bile duct without mention of cholecystitis, with obstruction acute venous embolism and thrombosis of unspecified deep vessels of lower extremity unspecified pruritic disorder postmenopausal bleeding 

Answer: The patient is high likely exposed to