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: quinolones / oxacillin attending: chief complaint: unresponsiveness major surgical or invasive procedure: central venous line history of present illness: 83 year old male with history of cad, cri, paf on coumadin, dm presents from rehab for unresponsiveness with a finger stick in the 20s discovered at rehab. he was noted to be cold and clammy and very restless. he was given glucose gel with improvement to the 150s initially. also per the nh notes, the patient had a seizure like episode lasting <1 minute and was persistantly unresponsive despite giving the glucose. ems saw him and got fs 100 but unarousable enroute to the ed. . of note, patient was recently admitted to for urosepsis; at which time he was treated with meropenem and subsequently tigecycline with cultures growing mdr klebsiella sensetive only to tigecycline. renal u/s at the time did not show evidence of collection and blood cultures remained negative. he was discharged to rehab and per the notes, he has not been eating over the past few days. they were also doing straight caths for poor uop (but was getting his flomax) . on arrival to the ed vitals were bp 105/50 t96 hr 90 100%ra; fingerstick 15 on arrival and he was given dextrose with improvement to 92 and mental status improved. ct head done initially neegative. but then bp started to drop around 7:30am to sbp70s. he was given 4l ivf, vanc/zosyn given initially and cvl placed. additional history per the wife obtained regarding recent uti and thus tigecycline given. blood cultures were drawn and picc line removed. he started to desat to 93% and make brisk uop; so fluids held and patient was started on low dose levophed. finger stick done again and noted to be 40 so d5 started. patients labs notable for wbc 10.2, lactate 0.8, inr 3.0, ck 40 trop 0.03, cr 2.3. glucose 17-->repeat 92 but then 42 and started on d5. his mental status improved after the dextrose. u/a was grossly positive and given history he was given 100mg tigecycline. a cxr showed no evidence of pneumonia, blood cultures were sent. cvl was placed and patient received 4l ivf. levophed was started for persitant hypotension. picc line was removed and sent for culture. . currently patient denies any pain. denies cough, fevers, chills, n/v, abdominal discomfort, urinary urgency/frequency. past medical history: - uroepithelial cancer s/p left radical nephrectomy s/p uretal thrombus after biopsy s/p stent placement and recent removal - frequent uti's, recent urosepsis treated with tigecycline for mdr klebsiella; started for 3 week course - cad s/p mi with bms to lad x3, ptca to om' - cri baseline 2.5 - dm on insulin - htn - pvd - h/o tia - paroxysmal atrial fibrillation on coumadin - right cea - chf ef 55%; symtpoms are wheezing - cvas when off coumadin for procedure - rheumatoid arthritis- previously on methotrexate - duodenal ulcer s/p ugib - h/o kidney stones - gout- exacerbated by diuresis; on colchicine - peripheral neuropathy - foot drop (r) s/p back surgery - depression social history: lives at on family history: nc physical exam: physical exam on admission: vitals - bp 120/70 hr 62 rr16 100%2l general: nad, lying in bed, conversant heent: pupils 2mm reactive/equal bilaterally, mucous membranes dry neck: jvd not appreciated cardiac:irregularly irregular, no murmur appreciated lung: clear bilaterally, no wheeze or rhonchi abdomen: slightly firm but nontender, nondistended +bs in all quadrants ext: trace edema bilaterally neuro: alert to person, not place/date, slight l. facial droop . physical exam on transfer: vitals - t:97.6 bp 131/62 hr 103 rr21 100% on room air general: nad, lying in bed, conversant, not oriented to time or place heent: pupils 2mm reactive/equal bilaterally, mucous membranes moist neck: jvd not appreciated cardiac: irregularly irregular, no murmur appreciated lung: clear bilaterally, no wheeze or rhonchi abdomen: slightly firm but nontender, nondistended +bs in all quadrants ext: trace edema bilaterally. diffuse erythema and warmth from right toes to mid-dorsum of right foot, tender to palpation. erythema also noted at right medial maleolus and left big toe and second toe. neuro: alert to person, not place/date, slight l. facial droop derm: well-demarcated erythematous large patch at right antecubital region, non-tender to palpation. not warm to touch. diffuse erythema and warmth from right toes to mid-dorsum of right foot, tender to palpation. erythema also noted at right medial maleolus and left big toe and second toe. pertinent results: admission labs: 05:45am blood wbc-10.2 rbc-4.69 hgb-11.9* hct-38.7* mcv-82 mch-25.3* mchc-30.6* rdw-16.0* plt ct-292 05:45am blood neuts-67.6 lymphs-25.1 monos-5.3 eos-1.6 baso-0.3 05:45am blood pt-30.5* ptt-48.2* inr(pt)-3.0* 05:45am blood glucose-17* urean-77* creat-2.3* na-135 k-4.8 cl-100 hco3-29 angap-11 05:45am blood lipase-70* 05:45am blood calcium-8.8 phos-3.3 mg-2.2 cardiac enzymes: 08:57pm ck(cpk)-36* 08:57pm ck-mb-notdone ctropnt-0.03* 02:51pm glucose-77 lactate-0.9 02:30pm ck(cpk)-37* 02:30pm ctropnt-0.03* discharge labs: 06:22am blood wbc-6.5 rbc-4.19* hgb-11.3* hct-36.5* mcv-87 mch-27.0 mchc-31.0 rdw-16.9* plt ct-207 06:22am blood pt-26.4* ptt-42.6* inr(pt)-2.6* 06:22am blood glucose-150* urean-38* creat-1.6* na-137 k-5.4* cl-104 hco3-25 angap-13 06:22am blood calcium-8.4 phos-2.6* mg-2.0 microbiology: 7:50 am urine site: catheter urine culture (preliminary): klebsiella pneumoniae. >100,000 organisms/ml.. tigecycline sensitivity requested per . sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s nitrofurantoin-------- 256 r piperacillin/tazo----- =>128 r tobramycin------------ 8 i trimethoprim/sulfa---- =>16 r . picc catheter tip : no growth. blood cx : no growth. . studies: . ekg: atrial fibrillation, twi in ii, iii, avf and v4-6. . cxr : impression: 1. normal study. 2. paramedian radiopaque wires not located or fully identified, could be external to the patient. correlation physical examination if needed additional views is recommended. . ct head : impression: 1. no acute intracranial process. 2. age-appropriate involutional changes. 3. chronic small vessel ischemic disease and lacunar infarcts. . renal us : impression: 1. no hydronephrosis or discrete fluid collection seen. 2. heterogeneous appearance of the right kidney. examination is limited for evaluation of known right metastasis. recommend correlation with prior imaging and/or ct/mri as indicated. brief hospital course: 83 yo male with h/o cad, paf, chf, renal cell ca, cri presents with unresponsiveness found to be hypoglycemic and have uti. . # hypotension: on presentation, patient presented with sbp into 70s with a cvl placed and he was given fluids(4l) with modest improvement and subsequently started on levophed. the etiology may have been sepsis vs volume depletion. patient's blood pressure quickly stabilized. he was continued on tigecycline and weaned off of levophed within 24 hours of arrival to the icu. aside from the urine culture, the blood and picc line cultures showed no growth. patient was normotensive during the rest of his hospital stay. . # urinary tract infection: he was found to have a positive u/a with >50wbcs (he was getting straight cath'd at rehab); he was currently being treated for a uti at rehab (picc in place); sensetivities from reveal klebsiella uti sensetive only to tigecycline (mic of 1 and urine cultures at had cleared by ). repeat urine cultures returned on show klebsiella sensetive to gentamycin, ertapenem and meropenem. tigecycline sensitivity at mic 3 mcg/ml. therefore, it appears that the two esbl klebsiella strains (the strain and the strain) are different. the fact that the urine culture grew out esbl klebsiella when patient was taking tigecycline was concerning for colonization of the urinary tract by these very resistant bacteria. renal ultrasound was done which showed no evidence of fluid collection/abscess. id was consulted who recommended to continue tigecycline for the planned 3 week course. patient was set up to see his outpatient urologist at , dr. , after discharge. patient's pcp was informed of the strain differences between the two esbl klebsiella strains, and was asked to refer the patient to outpatient id for followup. . # urinary retention: patient's flomax was initially held in the setting of hypotension, which was restarted when blood pressure was more stabilized. patient required scheduled straight cath. urinary retention is very likely contributing to patient's persistent uti. patient's outpatient urologist, dr. , was contact and updated, and a followup appointment was made for him. on discussion with dr. , it appears that suprapubic cath is planned in the future. . # unresponsiveness: pt was found unresponsive; glucose on presentation was 15; mental status improved after dextrose load. ct head was negative. mental status changes were due to profound hypoglycemia as it was back at baseline with normalization of glucose. . # hypoglycemia/dm: patient presented with a finger stick of 15; he was persistantly hypoglycemic despite dextrose, which may have been due to the long acting lantus that was just resumed at rehab in the setting of poor po intake. he was initially monitored with q1 hour finger sticks and started on d10 gtt; finger sticks then began to improve and d10 stopped. insulin sliding scale was resumed gently after glucose was in the 200s. patient was discharged with 5u glargine qhs and humalog sliding scale. . # cri: pt's creatinine was 2.1 on admission, which is baseline per his pcp. creatinine was stable during this hospital stay. . # cad: pt has history of cad; ekg with twi and no old ekg for comparison. cardiac enzymes remained flat. he was continued on aspirin. metoprolol was re-introduced after blood pressure was stabilized. his statin was continued. patient had no chest pain or shortness of breath during this admission. . # paf: patient is v-paced but intermittently in afib. coumadin was continued. metoprolol was re-introduced after blood pressure was stabilized. hr remained well controlled. . # chf: lasix was held on admission, and restarted on discharge. . # right foot pain with erythema: differential includes cellulitis vs gout. he was given colchicine per his home regimen but the erythema was worsening on hospital day 2. id was then consulted. given that he was on such broad spectrum antibiotics (tigecycline), id thought this is unlikely cellulitis, and more consistent with gout. patient was continued on colchicine, and gout continued to improve on this treatment. . # code: full (confirmed) . # contact: wife (h) (c) medications on admission: lopressor 100mg omeprazole 20mg simvastatin 20mg daily flomax 0.8mg (does not urine without this per pcp) coumadin- 2.5mg qhs cymbalta 60mg daily colchicine 0.6mg qod insulin (lantus 20qhs, regular iss) lasix 40mg daily tigecycline 50mg q12 nystatin prn iron 325mg daily latrisone lactinex tylenol 650mg prn bisacodyl 20mg rectal daily senna powder daily vitamin d 1000u daily calcium carbonate 650 mvi loperamide 2mg 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. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 4. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 5. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 6. colchicine 0.6 mg tablet sig: one (1) tablet po q48h (every 48 hours). 7. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 8. erythromycin 5 mg/g ointment sig: one (1) application ophthalmic qid (4 times a day). 9. nystatin-triamcinolone 100,000-0.1 unit/g-% cream sig: one (1) appl topical (2 times a day) as needed for yeast. 10. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 11. tigecycline 50 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours): last dose on . 12. flomax 0.4 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po once a day. 13. lasix 40 mg tablet sig: one (1) tablet po once a day. 14. iron 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 15. tylenol 325 mg tablet sig: two (2) tablet po four times a day as needed for fever or pain. 16. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. 17. calcium carbonate 650 mg (1,625 mg) tablet sig: one (1) tablet po twice a day. 18. multivitamin tablet sig: one (1) tablet po once a day. tablet(s) 19. insulin glargine subcutaneous 20. humalog 100 unit/ml cartridge sig: sliding scale subcutaneous qachs. 21. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 22. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po hs (at bedtime). 23. lasix 40 mg tablet sig: one (1) tablet po once a day: hold if sbp<95. 24. insulin glargine 100 unit/ml cartridge sig: five (5) unit subcutaneous at bedtime. 25. humalog 100 unit/ml cartridge sig: sliding scale subcutaneous qachs. discharge disposition: extended care facility: commons residence at orchard - (a.k.a. ) discharge diagnosis: primary diagnoses: - hypoglycemia - hypotension - uti with esbl klebsiella . secondary diagnoses: - cad - ckd - htn - pvd - h/o tia - paroxysmal atrial fibrillation on coumadin - chf 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 to be involved in your care, mr. . you were admitted to because you had low blood sugar, and your blood pressure was low. you were initially stabilized in the intensive care unit, and transferred to the regular medicine floor for continued care. your blood sugar and blood pressure have been stable during the hospital stay. while in the hospital, your urine culture grew out the same bacteria that you had while you were admitted to last time. you were continued on the antibiotic, tigecycline. you also had a gout flare on your right foot, and were treated with colchicine. your medications have been changed: - insulin dose was adjusted to avoid another episode of low blood sugar - metoprolol dose was decreased - please continue tigecycline until wednesday followup instructions: we have made a followup appointment for you to be seen by your urologist at on monday at 11am. please go to the building for your appointment. please call ( if you have any questions. please follow up with your primary care doctor, dr. , j. at , within the next week. procedure: venous catheterization, not elsewhere classified diagnoses: coronary atherosclerosis of native coronary artery urinary tract infection, site not specified congestive heart failure, unspecified friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (luts) paralysis agitans hypotension, unspecified diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin retention of urine, unspecified rheumatoid arthritis personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits carrier or suspected carrier of methicillin resistant staphylococcus aureus atherosclerosis of native arteries of the extremities, unspecified personal history of malignant neoplasm of kidney other candidiasis of other specified sites personal history of peptic ulcer disease conjunctivitis, unspecified gouty arthropathy, unspecified 

Answer: The patient is high likely exposed to