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: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: picc line placement history of present illness: m hx of dementia and depression, lower gi bleed with villous adenoma status post colostomy, pe on coumadin, afib and dm who presents from with with ams and lethargy. . in the ed, initial vs were 96.0 68 98/48 18 99%/ra. labs were notable for na 159, k 6.3, cr 5.2, gluc 140, wbc 13.2 76.5%n, inr 3.4, hct 40.4 and lactate of 2.1. cxr revealed no focal consolidation. head ct revealed no acute intracranial process. patient received 1 amp d50 and 10 units of insulin in the ed. renal fellow was consulted and advised emergent hd. . on arrival to the micu, pt appeared comfortable but was unarousable and therefore unable to answer questions. staff reported recent ftt (eats only food brought in by family who live several hours away). not aware of any recent fevers, chills or urinary symptoms. past medical history: b/l pulmonary emboli prostate ca villous adenoma s/p colectomy w/colostomy, with chronically prolapsed stoma dm2 anemia of chronic disease depression hx of ethanol use right hip fracture hypertension urethral strictures social history: immigrated from in . retired, lives in nursing home. widowed. 20-30 pack year history of smoking, quit 20 years ago. past ethanol abuse, none now. no illicits. daughter lives in , is hcp (home) (cell). step-daughter also aware but prefers not to be involved in medical decision-making. family history: non-contributory physical exam: admission exam vs t 98.2 hr 80 bp 117/57 rr 17 o2 98/ra general: alert, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: tachycardic to 110, normal s1 + s2, no murmurs, rubs, gallops lungs: good air entry b/l, but prolonged expiration, with diffuse expiratory wheezes b/l, fine crackles at bases, l>r abdomen: firm, non-tender, non-distended, hypoactive bowel sounds, no tenderness to percussion, no rebound gu: foley in place, no lesions, no scrotal edema ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact . discharge exam: physical exam: vitals: tm 99.1 97.8 140/80 (132-154/60-80) 93 (70-102) 93-98ra fsg 136 incontinent of urine general: alert and interactive this morning, aao x3 heent: sclera anicteric neck: supple, jvp not elevated, no lad cv: rrr, s1 s2, ? sem loudest at usb lungs: clear to auscultation b/l, with poor air movement abdomen: soft, nontender, nondistended, +bs, + ostomy with about 10 cm of prolapsed intestine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs 01:25am blood wbc-13.2*# rbc-4.37* hgb-11.9* hct-40.4 mcv-92 mch-27.1 mchc-29.4*# rdw-14.6 plt ct-233 01:25am blood neuts-76.5* lymphs-13.0* monos-7.3 eos-2.9 baso-0.3 01:25am blood pt-34.5* ptt-50.7* inr(pt)-3.4* 01:25am blood glucose-140* urean-108* creat-5.2*# na-159* k-7.1* cl-120* hco3-23 01:25am blood alt-22 ast-36 alkphos-98 totbili-0.3 01:25am blood lipase-89* 01:25am blood albumin-3.8 calcium-9.8 phos-6.0*# mg-3.1* 01:31am blood lactate-2.1* . urinalysis 07:54am urine color-yellow appear-hazy sp -1.015 07:54am urine blood-mod nitrite-pos protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-lg 07:54am urine rbc-29* wbc-41* bacteri-many yeast-none epi-0 07:54am urine casthy-111* . micro blood culture -pending blood culture -pending mrsa screen {positive for methicillin resistant staph aureus} urine culture-final {escherichia coli} blood culture - 2/4 bottles escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . _________________________________________________________ escherichia coli | amikacin-------------- <=2 s ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- 2 s ceftazidime----------- 16 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin/tazo----- s tobramycin------------ 8 i trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final ): reported to and read back by dr. @ , . gram negative rod(s). anaerobic bottle gram stain (final ): gram negative rod(s). discharge labs: 06:55am blood wbc-8.6 rbc-3.47* hgb-9.3* hct-30.6* mcv-88 mch-26.7* mchc-30.3* rdw-14.4 plt ct-161 06:01am blood wbc-8.2 rbc-3.14* hgb-8.5* hct-27.9* mcv-89 mch-26.9* mchc-30.3* rdw-14.9 plt ct-144* 01:25am blood neuts-76.5* lymphs-13.0* monos-7.3 eos-2.9 baso-0.3 06:55am blood glucose-183* urean-9 creat-1.1 na-142 k-3.7 cl-109* hco3-25 angap-12 06:01am blood glucose-122* urean-7 creat-0.9 na-145 k-3.4 cl-111* hco3-29 angap-8 06:55am blood calcium-8.0* phos-2.2* mg-1.8 06:01am blood calcium-8.4 phos-2.4* mg-1.6 brief hospital course: m nursing home resident w/hx colectomy villous adenoma, b/l pe, atrial fibrillation, dm2 and recent ftt was send in for ams, found to have sepsis from a urinary source, with arf, hypernatremia, & hyperkalemia. clinically improved w/ivf and antibiotics. # delirium patient has underlying dementia and recent ftt. however, staff report that at baseline he is conversational and appropriate. now p/w ams (lethargic, nonverbal, on neuro exam he did not respond to voice or sternal rub but did withdraw to pain). suspect ams the result of urosepsis (see below) plus metabolic encephalopathy, as patient was severely dehydrated on admission (clinically-apparent and reflected in hypernatremia to 159 and hyperkalemia >6 on admission). after transfer to the general medicine floor, the patient's mental status improved, as his blood and urine infection was treated with ertapenum(see below) and his hypernatremia was corrected (see below). # sepsis from urinary source pt p/w tachycardia, tachypnea, altered mental status, leukocytosis w/left-shift, and hypotension. blood cultures and urine cultures drawn in the ed grew e coli, sensitive to cefepime. he was started on cefepime on admission. also received continuous ivf. wbc count, hr and mental status normalized within 48h. the patient's antibiotics were switched from cefepime to meropenum after discussing with id, as his urine e. coli was only intermediately sensitive to the cefepime. because of the positive blood cultures, the patient will have to continue 2 weeks of ertapenum since 1st negative blood culture. # hypernatremia na 159 on admission. patient has a 3.8l free water deficit. initiated ivf therapy w/d51/2ns. sodium initially corrected very slow due to access difficulties (limited to one 22gauge iv - cvl placement attempt failed on hd1). once access was obtained via picc on hd2, pt was given d5w and na rapidly corrected to 143. fluids held overnight - na jumped to 156. d51/2ns started on the morning of hd3 - na corrected steadily thereafter. pt transferred from the micu to the floor when na dropped to 150. while on the general medicine floor, the patient's sodium continued to trend down; he was maintained on d5 half normal saline, with q6h lyte check. the rates of the ivf were adjusted as needed to ensure that the patient was not being corrected too fast. when his sodium was stable and the patient was taking good po intake, ivf were discontinued. # acute-on-chronic renal failure patient has history of labile renal function, baseline cr 1.1-1.3. cr was 5.2 on admission - thought to be reflective of severe dehydration as gfr improved rapidly with ivf (1.6 at time of micu-to-floor transfer). renal consult service followed closely and assisted with electrolyte management. the patient's creat continued to trend down while on the general medicine floor while getting ivf. upon discharge, the patient's creatinine was 0.9. # hyperkalemia patient was found to be profoundly hyperkalemic to 6.3 on arrival to the , he was given 10u insulin and an amp of d50. renal consulted in the ed for question of dialysis; pt admitted directly to the icu for this possible. k quickly corrected to <5 w/kayexelate and hydration (in addition to insulin/d50 given in the ed). home lasix also held in this setting. while on the medicine floor, the patient's potassium remained stable. # anticoagulation pt has hx multiple pes & atrial fibrillation. on warfarin - inr 3.4 on admission. patient was recently admitted in for gib from colostomy at which time warfarin was stopped. anticoagulation has aparently been resumed as an outpatient & he was again supratherapeutic on admission. held coumadin in the setting of supratheraputic inr. while on the medicine floor, the patient was restarted on his home dose coumadin, with goal inr closer to 2, given his history of gi bleeding in the past. upon discharge the patient's inr was elevated, and his coumadin was held. # htn patient was on lisinopril and metoprolol for htn at home. initially, the patient's lisinopril was held given arf; his lisinopril was ultimately held at discharge. this should be followed up as an outpatient and if needed, it should be restarted. #dm2 bs reportedly well-controlled on metformin at baseline. given reduced renal function and lactic acidosis, held metformin. managed sugars w/iss. transitional issues: - the patient was dnr/dni during this admission; his daughter is his hcp and it was decided to make the patient dnr/dni. this issue will have to be readdressed as an outpatient. - the patient will have to continue ertapenum for 2 weeks; he had picc placed during this admission. stop date for ertapenum . - please continue to encourage good po. - the patient's lisinopril was held at discharge; his pressures will have to be followed as an outpatient and if needed, restarted. - the patient's inr was 3.0 the day of discharge; given his history of gib, target inr should be closer to 2.0. his dose of coumadin was held the day of discharge; this will have to be followed up, and inr checked on . medications on admission: - metformin 500 mg qam and 250 mg qpm - aspirin 81 mg daily - lactulose 30 ml qid:prn constipation - sertraline 25 mg daily - brimonidine 0.15 % drops - lisinopril 20 mg daily - mirtazapine 15 mg qhs - warfarin 4 mg daily - acetaminophen 500 mg :prn pain - senna 8.6 mg :prn constipation - colace 100 mg - milk of magnesia 400 mg/5 ml daily:prn constipation - albuterol sulfate 2.5 mg /3 ml (0.083 %) q6h:prn wheezing - mucinex 600 mg prn cough - metoprolol succinate 25 mg daily - multivitamin daily discharge medications: 1. metformin (glucophage) 500 mg po qam 2. metformin (glucophage) 250 mg po qpm 3. aspirin 81 mg po daily 4. lactulose 30 ml po q6h:prn constipation 5. sertraline 25 mg po daily 6. brimonidine tartrate 0.15% ophth. 1 drop both eyes 7. mirtazapine 15 mg po hs 8. acetaminophen 500 mg po bid:prn pain 9. senna 1 tab po bid:prn constipation 10. docusate sodium 100 mg po bid 11. milk of magnesia 30 ml po q6h:prn constipation 12. albuterol 0.083% neb soln 1 neb ih q6h:prn wheezing 13. mucinex *nf* (guaifenesin) 600 mg oral prn cough 14. metoprolol succinate xl 25 mg po daily please hold for sbp<100, hr<60 15. multivitamins 1 tab po daily 16. warfarin 4 mg po daily16 17. ertapenem *nf* 1 gram intravenous daily duration: 10 days please stop on discharge disposition: extended care facility: healthcare center - discharge diagnosis: primary diagnosis: metabolic encephalopathy hypernatremia acute renal failure e. coli septicemia e. coli urinary tract infection secondary diagnosis: dementia depression atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you while you were hospitalized at . you were admitted to the hospital because you were found to be lethargic and confused at your facility. we found that you had an infection in your blood and urine, which we treated with antibiotics. the sodium levels in your blood were also very elevated; we think this is because you have not been eating or drinking enough. we fixed these sodium levels by giving you fluid through your veins. it is very important that you continue to eat and drink well at the facility. we made the following changes to your medications: start ertapenum 1 gram through your veins daily (stop date ) stop lisinopril 20 mg daily followup instructions: please follow up with your primary care doctor within one week of leaving the hospital. md procedure: venous catheterization, not elsewhere classified diagnoses: hyperpotassemia anemia of other chronic disease urinary tract infection, site not specified toxic encephalopathy diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation personal history of malignant neoplasm of prostate depressive disorder, not elsewhere classified chronic kidney disease, unspecified bacteremia long-term (current) use of anticoagulants methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site do not resuscitate status hyperosmolality and/or hypernatremia colostomy status personal history of pulmonary embolism other and unspecified escherichia coli [e. coli] dementia, unspecified, without behavioral disturbance 

Answer: The patient is high likely exposed to