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: hydrochlorothiazide attending: chief complaint: hepatobiliary sepsis and liver abscess major surgical or invasive procedure: percutaneous drain placed in liver history of present illness: mr. is an 84 year old male with a history of coronary artery disease, ischemic cardiomyopathy, pvd, and type 2 dm who was initially transferred to from hospital on with hepatobiliary sepsis and possible liver abscess after presenting with 1 week of fevers and chills, abdominal cramping, and anorexia. he was initially admitted to hospital on . his initial labs were concerning for obstructive hepatitis and biliary sepsis with elevated wbc, lfts including alk phos and tbili with elevated direct fraction. he also had elevated trop to 0.78 and acute renal failure with cr 2.7. he had a 5.4 cm liver lesion concerning for abscess. he was admitted and covered with broad spectrum antibiotics including zosyn and flagyl. he also received ns hydration. he was then transferred to for further management. upon arrival to , labs again confirmed picture of obstructive hepatopathy with leukocytosis to 16,000 and arf with cr 2.7. troponin was elevated here on arrival as well but cks were negative. other labs revealed anemia to 32 and no evidence of dic. ruq u/s here showed multiple liver lesions, largest in l lobe concerning for abscess. surgery was consulted and recommended a triple phase ct scan to prep for possible percutaneous drain placement. he was continued on zosyn and flagyl here and also had vancomycin added. on the evening of transfer, after returning from ct scan, patient began rigoring, became tachycardic to the 150s, hypothermic to 96 and then spiked a temp to 101.2. he maintained his sbps in 130s-140s. o2 requirement increased to 5l nc and his skin was diffusely mottled. at the time of evaluation on the floor, rigoring had stopped and he felt improved. however, tachycardia persisted despite fluid bolus. he was transferred to the icu and upon arrival to icu, required intubation and was briefly on pressors. during his time in the icu a percutaneous drain was placed in his liver by general surgery. eventually the patient was extubated and hemodynamically stable enough to be transferred to the floor. past medical history: # cad # ischemic cardiomyopathy, ef 40% # dm ii # hypertension # hypercholesterolemia # prior liver cyst in l lobe # pvd s/p bilateral aortoiliac stenting # cataract s/p prior surgery. # gout social history: >60 pack-year smoking history, quit 4 years ago. denies etoh or drug use. married. retired microwave engineer. family history: no history of stomach or hepatobiliary cancer. physical exam: physical exam on transfer to the floor: pe 97.5, 156/66, 68, 95% on 5l, wt 70.4, bg 143 gen: asian male, week, polite heent: nasal feeding tube in place, moist mm cv: regular. tachy. normal s1 and s2. pulses 2+. chest: wheezes at bases, no egophany, no rhonchi or crackles abd: +bs, nt, soft, small dry dressing on upper abdomen ext: no c/c/e. neuro: strength 3/5 in lower extremities, cn intact, a and o x 3 pertinent results: admission labs: 10:11pm wbc-16.0* rbc-3.93* hgb-12.3* hct-35.3* mcv-90 mch-31.2 mchc-34.7 rdw-13.9 10:11pm neuts-87.4* lymphs-9.2* monos-1.7* eos-1.1 basos-0.7 10:11pm plt count-441* 10:11pm pt-14.2* ptt-31.9 inr(pt)-1.2* 10:11pm glucose-240* urea n-56* creat-2.4* sodium-134 potassium-3.6 chloride-104 total co2-17* anion gap-17 10:45pm lactate-5.6* 11:50pm lactate-9.0* 06:35pm urine color-yellow appear-clear sp -1.010 06:35pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-sm urobilngn-1 ph-5.0 leuk-tr 06:35pm urine rbc-21-50* wbc-0-2 bacteria-occ yeast-none epi-0-2 03:34pm hbsag-negative hbs ab-negative hbc ab-negative igm hav-negative 03:34pm hcv ab-negative ------------------ micro: 10:00 pm blood culture source: line-central 2 of 2. **final report ** blood culture, routine (final ): klebsiella pneumoniae. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s anaerobic bottle gram stain (final ): gram negative rod(s). reported by phone to at 307 . aerobic bottle gram stain (final ): gram negative rod(s). 4:06 pm abscess source: liver abcess. gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): -------------------- 1:57 pm abscess source: abd abscess drainage from wound drain. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): gram positive rods. rare growth. unable to identify further. anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. --------------- pathology: fna, liver abscess: negative for malignant cells. abundant neutrophils and debris with rare group of epithelioid cells, probably reactive mesothelial cells --------------- imaging studies: ct abdomen/pelvis : 1. 5-cm cystic lesion within the left lobe of the liver, with suggestion of internal heterogeneity. concurrent ultrasound demonstrates marked internal debris and multi-septations. while this lesion is incompletely characterized without iv contrast, this is concerning for a hepatic abscess. additional vague hypodensities in the caudate lobe may also reflect additional abscesses. differential diagnosis for these lesion inludes necrotic metastases, although this seems less likely. the large lesion in the left lobe is amenable to aspiration/catheter drainage. (the latter was discussed with dr. on monday at 11:46am by dr. 2. foci of air within the bladder, with a foley catheter in place. several locules of air appear somewhat peripheral in location. this may be located within the lumen of the bladder related to instrumentation; however, correlation with a ua is recommended to exclude associated cystitis. 3. diverticulosis without diverticulitis. 4. hypodensities in bilateral kidneys, too small to characterize. -------------------- abdominal ultrasound : multiple, predominantly hypoechoic liver lesions with largest lesion located within the left lobe. given son features, this dominant lesion most likely represents an abscess. in the right clinical circumstances, this could represent a echinoccochal cyst with associated daughter cysts. recurrent pyogenic cholangitis is another possibility given the history of elevated bilirubin although in the abscence of biliary dilatation, this diagnosis is much less likely. mrcp and/or ercp are recommended for further evaluation. 2. cholelithiasis without evidence of acute cholecystitis. -------------------- ct abdomen and pelvis - 1. the left lobe of liver catheter is well positioned, with near complete resolution of the left hepatic lobe abscess. 2. multiple small additional hepatic collections are not amenable to percutaneous drainage at this time. there are several tiny adjacent collections within the caudate lobe, which are not amenable to percutaneous drainage. 3. interval development of small bilateral pleural effusions, ascites, and left basilar consolidation. -------------------- liver ultrasound impression: stable appearing liver. there is a small residual cavity which is not hypervascular and the appearance is not suggestive of an expanding abscess. chest xray : impression: increase in interstitial suggesting failure. brief hospital course: 84 year old male with a history of coronary artery disease, ischemic cardiomyopathy, pvd and dm transferred from hospital with hepatobiliary sepsis and liver abscess. #. klebsiella bacteremia/severe sepsis: the patient initally presented to osh where he was found to have fever, leukocytosis. ruq us showed a cystic hepatic mass concerning for infection. he was started on zosyn and flagyl and transferred to . on arrival to vancomycin was added and ct a/p was obtained demonstrating a 5-cm cystic lesion. shortly after transfer he became febrile and hemodynamically unstable and was transferred to micu where he was intubated and started on pressors. blood cultures from grew klebsiella. id was consulted and cipro was added as well as a one time dose of gentamicin. source control for liver abscess as below. the patient was extbuated after 12 days with eventual wean of pressors. vancomycin was discontinued on . zosyn was discontinued on day 19 of treatment due to eosinophilia and new onset low grade fever and meropenem was begun. following this antibiotic change the patient remained afebrile. the plan for the patient's antibiotic regimen at time of discharge is to discontinue meropenem and begin ertapenem. he is scheduled to complete ertapenem on (this will complete a total of a 6 week course of antibiotics). patient scheduled to follow up in infectious disease clinic on . #. liver abscess: the patient was started on zosyn as above and switched to meropenem. he underwent ct guided drainage of left lobe liver abscess on . cultures from drainage yielded no growth. he underwent repeat ct a/p on demonstrating near complete resolution of the left hepatic lobe abscess and multiple small additional hepatic collections which were not amenable to percutaneous drainage. the drain was removed prior to the transfer from the micu to the floor. as noted above, he will be transitioned to ertapenem for daily dosing upon discharge and complete a total of 6 weeks of antibiotics on . he is scheduled to have a repeat liver ultrasound on at 10:15 am (should be npo for 6 hrs prior to study). #. hypoxemic respiratory failure: pt was intubated in the setting of sepsis as above. he developed significant volume overload from fluid resuscitation and arf. following the resolution of his sepsis he was diuresed with lasix and weaned from ventilator. his oxygen requirements continued to improve with lasix 40mg iv daily and he was transitioned to oral lasix at time of discharge- lasix 80 mg daily up from home dose of 20 mg daily. patient continued to require 3l of oxygen via nasal cannula- o2 sat at rest 94-96% on 3l. patient's oxygen should continue to be weaned as tolerated and lasix may need to be adjusted to ensure proper level of diuresis. can also continue nebulizer treatments as needed. #. acute renal failure: patient developed acute renal failure in the setting of sepsis likely related to overwhelming infection and hypovolemia. creatinine peaked at 2.7 and has since stabilized at 1.3. renal function should continue to be monitored closely and medications should be renally dosed. #. hypertension: following resolution of sepsis patient was started on carvedilol to 25mg . he was also started on hydralazine 50mg po tid with the expectation that he would be transitioned to an ace inhibitor when his kidney function improved. patient's home regimen of metoprolol, amlodipine and clonidine were discontinued. at time of discharge patient's blood pressure remained in a normotensive range. hydralazine was discontinued and he was started on lisinopril 10 mg daily. the lisinopril will likely need to be titrated up. in summary, anti-hypertensive regimen now consists of carvedilol and lisinopril which should also benefit his heart failure. #. anemia of chronic disease: patient requried two packed red blood cell transfusions during this admission. following transfusions hct remained stable. iron studies indicated anemia of chronic disease given fe:64, ferritin:507*, tibc:229*. hct stable 27-29 at time of discharge. #. systolic chf: echo on demonstrated ef 30-35%. as noted above, while intubated the patient developed significant volume overload secondary to fluid resucitation while he was septic. the patient was successfully extubated. patient continued on 40 mg iv lasix daily in order to continue diuresis. cxr on continued to show persistent failure. patient transitioned to 80 mg oral lasix daily. he was also continued on carvedilol and started on lisinopril. #. type ii diabetes mellitus: patient's outpatient glipizide held during this admission. pt initiated on glargine 20 units qhs in addition to a humalog sliding scale which was likely necesitated being on tf. the morning of discharge patient's blood sugar dropped to 29 from 140 in the pm (though he did get 2 of humalog) which likely reflects that glargine dose too high. we recommend reduced glargine from 20 units qhs to 10 units qhs. this may need to be titrated up if am blood sugar continue to run high. patient will likely need outpatient medication changes given he was only on glipizide coming in. #. gout: during this admission patient's allopurinol held given acute renal failure and significantly reduced gfr. on day prior to discharge patient developed discomfort on the plantar surface of his left great toe but no joint pain, swelling or erythema. seems unlikely that this pain represents a gout flare. given improved renal function patient restarted on allopurinol 100mg daily. giving percocet for pain control. would suggest monitoring for any evidence of acute flare developing. #. speech and swallow evaluation: upon initial evaluation speech and swallow team felt patient had severe oral-pharyngeal dysphagia and recommended that an ng tube be placed and he remain npo. patient was advanced to purees and nectar thickened liquids with supervision and with chin tuck manuever with 1:1 supervision. a calorie count was instituted. ng was removed when patient able to take enough calories po to maintain good nutrition. a repeat video swallow on indicated that diet could be advanced to soft (dysphagia); thin liquids a. 1:1 supervision for all pos. , b. chin tuck for all swallows, liquids and solids., c. alternate bites and sips., d. provide cues and reminders as needed to use chin tuck. # hematuria: pt had hematuria following foley removal likely trauma. this resolved. #. vitamin d deficiency: on admission patient reportedly taking ergocalciferol 5000 units daily. unclear how long he has been on this regimen. would suggest changing to vitamin d 800 mg daily and rechecking a hydroxyvitamin d. #gastroesophageal reflux disease: stable during this admission. omperazole changed to pantoprazole while patient unable to take npo. changed back to omeprazole at time of discharge. # bph: pt continued on his outpatient regimen of tamsulosin patient was a full code during this admission. medications on admission: aspirin 325mg daily allopurinol 100mg daily glipizide 2.5mg daily ergocalciferol 5000 units daily furosemide 20mg daily metoprolol 25mg daily omeprazole 20mg daily amlodipine 10mg daily atorvastatin 80mg daily at night tamsulosin 0.04mg daily at night clonidine dose unknown fish oil discharge medications: 1. ertapenem 1 gram recon soln sig: one (1) intravenous once a day for 22 days: last dose on . 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for 7 days: apply to groin . 5. acetaminophen 160 mg/5 ml solution sig: one (1) po q6h (every 6 hours) as needed. 6. carvedilol 12.5 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 q4h (every 4 hours) as needed. 8. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 9. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 10. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 11. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 12. insulin glargine 100 unit/ml solution sig: 10 units subcutaneous at bedtime: may need to be titrated up. 13. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous qachs: per sliding scale. 14. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 15. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 16. liver u/s scheduled for at discharge disposition: extended care facility: medical center - discharge diagnosis: primary: klebsiella bacteremia, liver abscess, acute renal failure, respiratory failure secondary: hypertension, type ii diabetes mellitus, gout, anemia of chronic disease discharge condition: stable, afebrile discharge instructions: you were transferred to this hospital because you were found to have an infection involving your liver. you were intitially in the icu and required intubation. you received intravenous fluids and intravenous antibiotics. your condition stabilized, you were extubated and transferred to the medical floor. we continued your antibiotics for the infection in your blood and liver. we also monitored your kidney function which was initially impaired, but has now improved. you will need to continue taking this antibiotic until . you will also need to have a repeat ultrasound of your liver which we have scheduled for . you were started on the following new medications: -ertapenem: this is an antibiotic that you will need to continue until -lantus: this is a type of insulin that you need for blood sugar control. your doctors at rehab decide whether you will continue this medication when you go home. -humalog: this is a short acting insulin that also acts to control your blood sugar again, your rehab doctor will determine if you need to go home on this medication. -lisinopril: this is a blood pressure medication -carvedilol: this is a blood pressure medication -vitamin d 800 mg daily the following changes have been made to your medications: -your lasix dose was increased to 80 mg. this may be altered when you leave rehab. the following medications have been stopped: -metoprolol -amlodipine -clonidine -ergocalciferol if you experience fevers, chills, sweats, chest pain, or difficulty breathing please contact your primary care condition or go to the emergency department for evaluation. followup instructions: provider: (liver ultrasound )phone: date/time: 10:30. . provider: , md (infectious disease) phone: date/time: 10:30 you will need to schedule a pcp follow up when patient is ready to leave rehab procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube transfusion of packed cells percutaneous aspiration of liver diagnoses: anemia of other chronic disease subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery esophageal reflux pure hypercholesterolemia acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis gout, unspecified peripheral vascular disease, unspecified other specified forms of chronic ischemic heart disease acute respiratory failure other specified cardiac dysrhythmias septic shock abscess of liver pressure ulcer, buttock other septicemia due to gram-negative organisms acute on chronic systolic heart failure pressure ulcer, stage ii 

Answer: The patient is high likely exposed to