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: rash, hypotension major surgical or invasive procedure: -central line placement -arterial line placement history of present illness: this is a 64 year old female with a history of pustular psoriasis and hypertension who presents with hypotension. she was in her usual state of health until 2-3 weeks ago when she began to note a rash consistent with her psoriasis throughout her body sparing her face. she was seen by her pcp who gave her what appears to be a 2 week course of prednisone, completed 1 week ago. her rash was accompanied by nausea and vomitting. she also felt chills and subjective fevers and began to have worsening lightheadedness and sob on exertion. she notes that this is consistent with her prior flare of pustular psoriasis that led to a hospitalization in . she was seen first at an osh where she was noted to have sbp 60s and was given 4 l ns and started on levophed and rij placed. she was also given hydrocortisone 50 mg iv x 1, vancomycin and zosyn. at ed her vitals were 98.8 (tmax 100.3), 113/53, hr 96, rr 18, 96% 2l. she was seen by dermatology who performed a skin biopsy and she was transferred to the . on the floor, she reports pain along her rash, improved from before and mild nausea. review of sytems: (+) per hpi (-) denied chest pain or tightness, palpitations. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: hypertension pustular psoriasis- was on soriatane until 3 months ago. social history: lives with husband in . works as a business office manager at a surgery clinic. denies etoh or tobacco. family history: father with psoriasis physical exam: admission: vitals: t: 97.7 bp:111/60 p: 96 r: 19 o2: 97% 3l general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad, rij site c/d/i lungs: bibasilar crackles, 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 ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: diffuse erythemaous scaly plaques sparing palms, soles and face pertinent results: **final report * urine culture (final ): klebsiella pneumoniae ampicillin/sulbactam-- 8 s 4 s cefazolin------------- <=4 s <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- <=16 s <=16 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s blood cultures: ngtd discharge labs: - cbc: wbc-6.4 rbc-3.18* hgb-9.4* hct-29.0* mcv-91 mch-29.6 mchc-32.5 rdw-16.5* plt ct-391 - chem 7: glucose-128* urean-30* creat-1.7* na-142 k-4.0 cl-107 hco3-25 calcium-8.7 phos-4.5 mg-2.0 uricacd-8.5* - iron studies: caltibc-230* ferritn-509* trf-177* imaging: renal u/s: the right kidney measures 9.2 cm and the left kidney measures 9.9 cm. there is no hydronephrosis, mass or calculus seen in either kidney. there is a 1.8 x 1.8 x 1.5 cm simple cyst arising from the interpolar region of the right kidney. the urinary bladder is well distended and is unremarkable. impression: no evidence of hydronephrosis echocardiogram: the left atrium is mildly dilated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. impression: normal biventricular regional and global systolic function. mild aortic regurgitation. mild mitral regurgitation. moderate pulmonary artery systolic hypertension. no vegetation identified. pathology: skin, right upper arm (a): subcorneal pustule formation with adjacent spongiotic epidermal hyperplasia and numerous intraepidermal and superficial dermal neutrophils (see note). note: scattered gram positive cocci are noted within the superficial stratum corneum; otherwise, no micro-organisms are identified in gms, pas, and gram-stained sections. in conjunction with the clinical history, the histologic findings are most consistent with pustular psoriasis with impetiginization; however, a pustular drug eruption / acute generalized exanthematous pustulosis cannot be entirely excluded. case reviewed by dr. , who concurs with this interpretation brief hospital course: 64 yo female with a history of pustular psoriasis transferred from osh with cutaneous eruptions, mssa bacteremia, septic shock. # septic shock: pressures initially maintained on levophed, with agressive ivf support (tbb +21l in icu). also received vancomycin/zosyn. she was weaned off pressors within 48h. osh bld cx noted to grow mssa (see below) and patient was started on nafcillin. urine culture with two different klebsiella species (see below) and patient was started in ciprofloxacin. osh central line was discontinued, and all blood and tip cultures during hospitalization at were negative. after pressors were weaned in the icu, patient remained normotensive with no episodes of hypotension during the hospitalization. # acute eruption of pustular psoriasis: evaluated by dermatology with biopsy. clinical exam, history, and biopsy c/w flare of pustular psoriasis flare with mssa superinfection. psoriasis was on her extremities and torso, but spared her palms/soles/face. notably, she had slurred speech, flushing and pruritic reaction post-soriatane, which the patient says is normal for her. patient was started on soriatane 50 per derm with good effect and improvement of her psoriatic patches. she will be continued on this as an out patient and need q1-2 week lft monitoring until lft's are stable. additionally, she should have her lipids checked in weeks. she has also received benadryl prn for itching while on treatment. patient also started on prednisone 10mg () per dermatology, which was tapered to 5mg and then discontinued (). wound care, per dermatology, included clobetasol, muporicin, and initial saran wrapping which were discontinued prior to discharge. psoriatic lesions improved during hospitalization and remained stable for several days prior to discharge. #mssa bacteremia: osh bld cx with mssa. patient started on nafcillin 2g iv q6h () with plan to complete 14d course (). a tte was performed and was negative for vegetation, with preserved systolic function. following antibiotic initiation patient remained afebrile during hospitalization. #uti: urine culture with two distinct klebsiella species (pan-sensitive). patient completed 6d course of ciprfloxacin 500mg po q12h for complicated cystitis (). plan was initially for 7d course, but regimen was discontinued after 6d secondary to concern of potential ciprofloxacin related ain (see below, discontinuation per renal). of note, at time of discontinuation patient was afebrile x5d with no urinary symptoms. concern for persistent infection was low. # acute renal failure: patient's cr on admission 2.2 (unknown baseline) thought to be most likely hypotension. creatinine nadir of 1 during icu stay and subsequently increased to peak of 2 in the setting of multiple medication exposures. urine electrolytes were c/w atn though the possibility of ain could not be ruled out. patient seen by renal who felt ain was a possibility, with potential agents including ppi, ciprofloxacin, nafcillin, soriatane. additionally, given modestly elevated serum uric acid level, and modestly elevated urine uric acid/cre ratio, the possibility of a psoriasis-related urate nephropathy was also considered. of note, patient was initially noted to be oliguric during icu course, though secondary phase of arf was associated with adequate uop. on discharge her cre had decreased from 2 to 1.9 to 1.7. given the reassuring cre trend, the decision was made that she was safe for discharge with repeat serum chemistries to be drawn on and called to her physician's office. #hypoxemia: on hospital day patient complained of worsening dyspnea, with a stable o2 requirement of 1.5-2l. a cxr at the time showed potential interval development of a rml/rll opacity. consideration was given to hap vs. fluid overload vs. psoriasis related ards/. hypoxemia resolved with a single dose of lasix. patient remained afebrile, with no other si/sx of pna and empiric coverage was not initiated. # hypertension: patient's home regimen (diovan 30mg qd, hctz 12.5mg qd, lasix 20mg qd) was held given initial hypotension. sbp during hospitalization ranged 120-140 and regimen was held given noted renal failure above. on discharge patients sbp continue to range between 120-140. given the evolving nature of her arf the decision was made to not restart her home regimen and defer consideration to pcp (pcp f/u made as below). #anemia: patient recieved 1u prbc during icu course for hct 24 in the setting of mild chest pain (hct 32 on admission; hct nadir with likely dilutional component given agressive ivf in icu of 22l and concomitant decrease of other cell lines at the time). an ekg at the time showed no e/o ischemia. following transfusion, hct was stably 28-30 without intervention. iron studies were consistent with aocd and a stool guiac was negative. #code: full medications on admission: 1. diovan 30mg po qd 2. hctz 12.5 po qd 3. lasix 20mg prn (le edema) discharge medications: 1. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for pruritis. 2. nafcillin 2 gram recon soln sig: two (2) grams intravenous every six (6) hours for 8 days: last dose . disp:*64 grams* refills:*0* 3. 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. 4. acitretin-emollient no.26 25 mg kit sig: fifty (50) mg miscellaneous daily (): if dispensed in kit, please dispense adequate amount for 50mg qd for 30 days. disp:*30 tabs* refills:*2* 5. outpatient lab work please draw chem 7, and lft's (alt, ast, alk phos and total bilirubin) on . call results to dr. 6. percocet 5-325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain for 3 days: do not drive or drink alcohol while taking this medication. disp:*10 tablet(s)* refills:*0* discharge disposition: home with service facility: rockinghan vna & hospice discharge diagnosis: pustular psoriasism mssa bacteremia klebsiella uti acute renal failure hypoxemia discharge condition: stable. discharge instructions: you were admitted to the hospital with a flare of pustular psoriasis as well as low blood pressure that required you to be in the icu and were initially on medication to support your blood pressure. you also were found to have an infection of your bloodstream as well as your urine. you were started on appropriate and antibiotics for each infection. you have completed the treatment for the urine infection and will continue on treatment for the bloodstream infection at home. you were evaluated by dermatology who recommended soriatane for the treatment of your pustular psoriasis. during your hospitalization you were found to be in renal failure. you were evaluated by the renal service who felt the renal failure may have been due to one of the medications you were taking which was stopped. the renal failure may also have been secondary to your pustular psoriasis flare. your renal function improved and it will be recheck on monday and the results given to your pcp. the following medication changes were made: added: soriatane, for your psoriasis added: nafcillin - last dose for your bloodstream infection stopped: diovan 30mg po qd - your pcp may restart stopped: hctz 12.5 po qd - your pcp may restart stopped: lasix 20mg prn (le edema) - your pcp may restart these blood pressure medications were stopped because they can worsen renal failure and your blood pressure was well controlled while you were here. your pcp may restart them when you see her next week. if you have heart burn, you can take ranitidine (zantac), please do not take omeprazole as it could worsen your renal failure. please return to the ed if you notice new or worsening skin lesions/eruptions, fevers/chills, worsening headache, shortness of breath, abdominal pain, diarrhea, difficult or painful urination, or anything that is concerning to you. it was a pleasure meeting you and participating in your care. followup instructions: please follow-up with your primary care physician . (appointment has been made for at 3pm). you also have a appointment with dr. at the in dermatology. if you would like to see a kidney doctor, you can reach the division at (. procedure: venous catheterization, not elsewhere classified closed biopsy of skin and subcutaneous tissue diagnoses: anemia of other chronic disease acute kidney failure with lesion of tubular necrosis unspecified essential hypertension severe sepsis methicillin susceptible staphylococcus aureus septicemia septic shock hypoxemia other psoriasis acute cystitis 

Answer: The patient is high likely exposed to