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 / cefepime attending: chief complaint: abdominal distension and shortness of breath major surgical or invasive procedure: thoracentesis paracentesis history of present illness: 69 year old woman with primary sclerosing cholangitis with cirrhosis (decompensated with ascites, hydrothorax, and encephalopathy) who presents from rehab facility with 4/4 gnr in blood. she was recently admitted with worsening abdominal distension and shortness of breath (like from increased ascites). she had several issues that should be considered seperately: . 1. cxr showed a rll opacity that was concerning for pneumonia. found to have klebsiella pneumoniae bacteremia, and completed a 2 week course of cefepime and bactrim (sensitive to both). her course ended . repeat blood cultures on were negative. she then spiked to 102.4 on and was pancultured. she was started back on vancomycin and cefepime. her cultures then grew out 4/4 bottles of vre (unknown source). she was started on daptomycin and developed a drug rash that was ultimately determined (by conference with id, derm and liver) to be related to cefepime. she was discharged to complete a course on and to resume gnr prophylaxis with ciprofloxacin 500mg daily (id wanted to start this given her large ascites) . 2. she is s/p chest tube placement and removal for massive pleural effusion. . 3.she had a lgi bleed from external hemorrhoids on and had and egd which showed grade 3 varices. she got 2 units of blood and remained stable. . she presents today with symptoms that recapitulate the excellent dc summary from rehab. namely, she was discharged to the macu for rehab and to complete the course of her daptomycin. since then she was seen in daycare ofr a 4 para w/albumin on . on , she spiked to 102.0. blood cultures, cxr and ua/ucx were ordered in a reflexive fever workuup. a cxr demonstrated a rul and lll infiltrate with persistent bilateral effsuions, worse than those evaluated on . on bcx came back postive for gnr. urine was positive for 2 types of gnr with 10 and 20k colonies. she had a wbc of 8.8, hct 25.5, plt 163; na 138, k 5.0, co 20, cr 0.7 and bun of 24. she was given 20mg of iv lasix with nebulizers with 500 cc of uop. a decision was made to transfer. with stable vital signs, she was transferred to for a thorough evaluation. much of which was undertaken by dr. in the ed. . in the ed, ms. vs were: 98 76 122/50 24 95on4l. by my evaluation, these were 123/63, 93, 26, 97on4l. she received a cxr that revealed, as above, new opacity in rul, effusions as before. a dx para was negative for sbp. and her labs, below, were within her baseline. she received 1g of meropenem at 5:30 and two piv's were placed. . review of systems: (+) per hpi (-) denies fever, chills, headache, congestion. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. past medical history: * primary sclerosing cholangitis: complicated by ascites, hydrothorax, encephalopathy, portal vein thrombosis * common bile duct stricture s/p hepatojejunostomy () * diabetes mellitus * invasive ductal carcinoma on the right breast (~), s/p femara 2.5mg every other day and lumpectomy with ?recurrence. portacath placed on left chest, never used for chemo, recently removed. managed at * history of idiopathic thrombocytopenia social history: patient previously lived at home in with her husband, . she recently went to rehab after her hospitalization in late , with plans to return home soon. she was employed as a nurse . denies tobacco, alcohol, illicit drugs. family history: non-contributory physical exam: vs: 98 76 122/50 24 95on4l. at 6pm: 123/63, 93, 26, 97on4l gen: comfortable, nad, aaox3 appears older than her stated age heent: anicteric, eomi cv: normal rate, regular rhythm. normal s1 and s2. 2/6 sem murmurs. no rubs, or gallops. pul: diffuse rales, r> l, bibasilar and rul. not cleared with cough abd: soft, non-distended. non-tender to palpation, feels pressure, no hepatosplenomegaly. diffuse maculopapular rash across her entire abdomen and back with increased confluence. ext: 2+ distal pulses bilaterally, 1+ pitting edema bilaterally to midshin skin: thin, warm, dry. pertinent results: 03:00pm blood wbc-5.8 rbc-2.56* hgb-8.1* hct-25.4* mcv-100* mch-31.8 mchc-32.0 rdw-16.0* plt ct-153 05:13am blood wbc-4.8 rbc-2.48* hgb-8.0* hct-24.8* mcv-100* mch-32.2* mchc-32.2 rdw-15.5 plt ct-162 03:00pm blood neuts-78.9* lymphs-8.9* monos-4.0 eos-7.4* baso-0.7 03:02am blood neuts-71.7* lymphs-10.1* monos-3.0 eos-14.7* baso-0.5 02:15pm blood pt-13.8* ptt-26.7 inr(pt)-1.2* 05:13am blood pt-13.3 ptt-28.1 inr(pt)-1.1 02:15pm blood glucose-194* urean-30* creat-0.7 na-136 k-4.3 cl-103 hco3-20* angap-17 05:13am blood glucose-115* urean-27* creat-0.6 na-138 k-5.1 cl-105 hco3-27 angap-11 02:15pm blood alt-46* ast-46* alkphos-174* totbili-1.1 05:13am blood alt-53* ast-56* ld(ldh)-212 alkphos-194* totbili-0.8 06:05am blood calcium-8.6 phos-3.1 mg-1.8 05:13am blood albumin-3.0* calcium-8.7 phos-3.4 mg-2.2 03:27pm blood type-art po2-64* pco2-54* ph-7.29* caltco2-27 base xs--1 comment-4l nc 02:47pm blood lactate-1.6 . 04:41pm pleural wbc-156* rbc-5300* polys-13* lymphs-60* monos-22* meso-5* 04:41pm pleural totprot-0.8 glucose-123 ld(ldh)-46 albumin-less than cholest-10 triglyc-66 04:40pm ascites wbc-66* rbc-600* polys-4* lymphs-40* monos-0 atyps-1* plasma-4* mesothe-2* macroph-49* 04:40pm ascites totpro-0.4 glucose-202 albumin-less than . blood, urine, and peritoneal cultures - all negative . cxr (): impression: new right upper lobe opacity concerning for infection. large right effusion and left basilar atelectasis. . cxr () - after 2 thoracenteses during hospitalization large right pleural effusion with almost white-out of the right hemithorax is unchanged. cardiomediastinal contours cannot be evaluated. small left pleural effusion with adjacent atelectasis is stable. there is no evident pneumothorax. left picc remains in place. . mri/mrcp (): impression: limited study due to motion, patient unable to cooperate, iv and oral contrast was not administrated. . 1. cirrhosis and segments of hepatic atrophy affecting the liver with fibrosis in keeping with patient's underlying primary sclerosing cholangitis. 2. similar degree of intrahepatic biliary duct dilatation. no evidence to suggest infected bile lakes. 3. non-occlusive thrombus in the main portal vein, suboptimally evaluated due to motion; however has not propagated into occlusive thrombus in the interval. 4. moderate right pleural effusion and atelectasis at the lung bases. 5. ascites, with interval increase in size compared to most recent mrcp. 6. splenomegaly. brief hospital course: 69 yo female with 69f with psc cirrhosis, previously decompensated by ascites, hydrothorax, and encephalopathy, with rapidly recurring hepatic hydrothorax and klebsiella bacteremia and multi-gnr uti, with suspected hcap. recent change in code status to dnr/dni . #. goals of care: after two recurrences of her hepatic hydrothorax and declining clinical state, we had many discussions concerning ms. goals of care. palliative care also visited with the patient. the results of these conversations are as follows: her code status has been changed to dnr/dni and she does not want to undergo any more invasive procedures to temporarily correct her shortness of breath. instead, we have prescribed her 2-6mg of morphine (liquid form) as needed for her shortness of breath. she also does not want to be re-admitted to the hospital should her condition worsen. however, this discussion will need to occur upon her arrival to the rehab center as well. our palliative care service will be in touch with their counterparts at rehab. all of her medications have been reviewed and we have only given her those that we feel will help her symptoms and make her comfortable. we have touched base with her oncologist, dr. , who will be deciding if she should continue on her femara while at rehab; she is aware that the patient is being transferred to rehab today. . # respiratory failure, secondary to pneumonia and hydrothorax - cxr upon admission showed a possible infiltrate and she was empirically covered for healthcare-associated pneumonia with vancomycin and meropenem. the patient was initially breathing comfortably on room air, but then decompensated with hypoxemia to the mid 80s. cxr showed a recurrent right-sided hydrothorax and a thoracentesis was performed in the icu. within hours, this fluid had re-accumulated, but she was satting well on 2-3l as was transferred back to the floor. it was determined by that she is not a candidate for tips due to her portal vein thrombosis and declining condition. she should continue on lasix 40mg + spironolactone 100mg for diuresis, re-started here on in the setting of improved hyponatremia. . # klebsiella bacteremia - blood cultures from rehab showed a pansensitive klebsiella, but she was kept on meropenem, given her history of vre bacteremia. all surveillance cultures done here at have been negative to date. a mri/mrcp was done to locate any possible sources that were causing recurrent gnr bacteremia, but did not show any bile lakes, biliary tree abnormalities, or abscesses. she should continue on meropenem until . . #. diabetes mellitus: she was continued on her lantus 8 units qhs and nph 20 units qam with blood glucose relatively well controlled in the 100s to 200s. upon addressing her goals of care, her insulin sliding scale and fingersticks were discontinued. . #. primary sclerosing cholangitis: previously complicated by ascites, hydrothorax, encephalopathy. we continued lactulose, with titration to bowel movements, and ursodiol. . # breast cancer: her oncologist, dr. , will decide if she should continue taking femara, given her change in her goals of care. . follow-up after discharge . 1) please continue iv meropenem 500mg q6h until 2) pull picc after antibiotic course completed 3) please re-discuss her dnr/dni as well as "do not hospitalize" wishes 4) coordinate with palliative care team at rehab (contact at is dr. ) 5) supplemental o2 as needed 6) no lab draws necessary 7) please re-confirm her follow-up appointments with pcp, , and id, as listed above. medications on admission: * rifaximin 600 * furosemide 40mg daily (down from 80) * glimepiride 4mg twice daily * glargine 9 units qhs * insulin 70/30 20 units qam * regular insulin ss. * lactulose 15-30cc by mouth twice daily, titrate to bowel movements * prilosec 40mg daily * spironolactone 25 mg (down from 200 daily) * ursodiol 500mg twice daily * calcium citrate - vitamin d3 315-200 units, two tabs twice daily * dapto 500 q24 *clobetasol * benadryl 25 q6 *lovenox 40 qpm * albuterol, atrovent nebs * sucralfate 1 gm qid discharge medications: 1. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 2. glimepiride 4 mg tablet sig: one (1) tablet po twice a day. 3. rifaximin 550 mg tablet sig: one (1) tablet po twice a day. 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 5. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 6. ursodiol 250 mg tablet sig: two (2) tablet po bid (2 times a day). 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for sob, cough. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q2h (every 2 hours) as needed for sob, cough. 9. letrozole 2.5 mg tablet sig: one (1) tablet po qother day (). 10. spironolactone 100 mg tablet sig: one (1) tablet po daily (daily). 11. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 12. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal tid prn () as needed for rectal discomfort. 13. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical daily (daily) as needed for itching. 14. insulin nph & regular human 100 unit/ml (70-30) suspension sig: twenty (20) units subcutaneous qam. 15. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q6h (every 6 hours): please give until . 16. lantus 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. 17. morphine 10 mg/5 ml solution sig: ml po q3h as needed for shortness of breath or wheezing. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnoses: recurrent hepatic hydrothorax klebsiella bacteremia klebsiella and enterobacter urinary tract infection hospital-acquired pneumonia . secondary diagnoses: primary sclerosing cholangitis cirrhosis breast cancer diabetes mellitus discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: it was a pleasure treating you at the . you were admitted to the hospital after you spiked a fever at rehab after taking antibiotics following your prior visit. we found that you had an infection in your blood and your urine and treated this appropriately with antibiotics. you were also short of breath upon arrival and a thoracentesis was done to take the fluids out of your lungs. during your time here, you got very short of breath again and needed to be moved the intensive care unit for a short time so they could take more fluid from your lungs. we had a discussion with you concerning what measures you would like us to take to make you feel better and it was decided that we would do our best not to do any invasive procedures and to not re-admit you to the hos rehab and will likely require supplemental oxygen while you are there. we have made the following changes to your medications, to focus on comfort and symptom relief: start meropenem 500mg iv every 6 hours, until start morphine liquid 2-6mg every 3 hours as needed for shortness of breath stop calcium carbonate stop vitamin d followup instructions: pcp: . : at 1:15pm. phone: , fax: . (): , np: at 10:00am, phone . flash, md (infectious disease, ) phone: date/time: 9:30 procedure: insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified thoracentesis thoracentesis percutaneous abdominal drainage diagnoses: pneumonia, organism unspecified urinary tract infection, site not specified cirrhosis of liver without mention of alcohol iron deficiency anemia secondary to blood loss (chronic) acute respiratory failure bacteremia other sequelae of chronic liver disease dermatitis due to drugs and medicines taken internally encounter for palliative care encephalopathy, unspecified accidents occurring in residential institution cholangitis cephalosporin group causing adverse effects in therapeutic use portal vein thrombosis malignant neoplasm of breast (female), unspecified other specified forms of effusion, except tuberculous 

Answer: The patient is high likely exposed to