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: hypoxia major surgical or invasive procedure: peripherally inserted central catheter central line placement (r ij) history of present illness: the pt is a 51-yo woman with t1-t2 paraplegia, copd, and multiple recent admissions for pneumonia, who comes in from home with hypoxia, somnolence, and cough productive of green sputum. the pt and husband confirm that she had been feeling very well until the morning of admission. on the morning of admission, the husband found her to be more difficult to arouse. he checked her oxygen saturation and found her to be 92-93% on 2l nc, but over the next few hours continued to be somnolent and with progressively worsening hypoxia to the low 80s on 2l nc and still less than 90% on 4l nc, so she was brought in to the ed. her husband also reports that she has had increased cough today, with green liquid/watery secretions, and feeling cold, but notes that she was warm to touch. he found her temperature to be 99f. she denies any chest pain, palpitations, shortness of breath, or wheeze. . on arrival to the ed, vs - temp 101.8f, bp 144/102, hr 110, r 24, sao2 81%. she was placed on nrb with improvement to 100%. cxr showed worsening rll process, and ecg was unremarkable. right ij cvl was placed due to difficulty gaining access, and blood cx were sent. she received 1l ns ivf, zosyn 4.5g iv, and vancomycin 1g iv. she is admitted to the micu for further care given her hypoxia requiring nrb. lactate was 1.5 and all other labs were pending at time of transfer. . of note, the pt was admitted for pneumonia from - with rll consolidations, treated with vancomycin and cefepime, with a brief admission to the micu for hypotension and fever that improved without intubation or pressors, transferred to the floor and ultimately discharged on a 7-day course of antibiotics. she was again admitted to from - with fever and hypoxia, which was thought to be related to a possible exacerbation of viral bronchitis with atelectasis. she was discharged with acappella for chest pt to aid in lung expansion and decrease oxygen dependence. she was feeling significantly improved on discharge and was doing very well at home until the day of admission. . ros: as per hpi. otherwise, she denies any headache, dizziness, lightheadedness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dysuria, arthralgias, or myalgias. . past medical history: 1. t1-t2 paraplegia following mvc 2. recurrent utis: klebsiella 3. hcv, viral load suppressed 4. h/o recurrent pnas: mrsa, pan-sensitive kleb 5. anxiety 6. dvt in -ivc filter placed in 7. pulmonary nodules 8. hypothyroidism 9. chronic pain 10. chronic gastritis 11. h/o obstructive lung disease 12. anemia of chronic disease 13. s/p pea arrest during last hospitalization in social history: - lives at home with her husband and 2 adolescent children - tobacco: 35 pack years, quit smoking several months ago, but relapsed recently (last cigarette was week of presentation). - etoh: denies - illicits: denies family history: no history of lung disease. physical exam: vs: temp 99.8f, bp 103/49, hr 101, r 21, sao2 93% nrb gen: ill appearing. on 4l nc. mild respiratory distress heent: pale conjunctiva. dry mm. poor dentition. no cervical lad. neck supple. r ij in place. cv: difficult to auscultate to coarse bs. rrr. no mrg appreciated. nl s1,s2 pulm: course breath sounds, rhonchorous throughout bilaterally r>l. exp wheezes present. wet craclkes in llf's b'l. abd: protuberant. nbs. nt. no hsm appreciated. gu: foley. chronic t1/t2 paraplegia. ext: 2+ pitting edema b/l up to the knee neuro: oriented to person, place, and time. pt. appears midly lethargic. cn ii-xii grossliy intact. sno sensation to touch below l2 dermatome bl. can twist abdomen and move arms. 5+ strength in ue b/l. skin: clammy, pale. 3x3 macule on r. foremarm. pertinent results: 05:05pm urine blood-neg nitrite-pos protein-25 glucose-neg ketone-tr bilirub-neg urobiln-neg ph-6.5 leuks-tr . . wbc 10.4 (93.3% pmns), hgb 9.8, hct 30.4, plt 210 na 139, k 3.6, cl 100, hco3 32, bun 13, cr 0.3, gluc 124 lactate 1.5 ua: clear yellow, ph 6.5, sg 1.024, trace leuks, positive nitrite, 25 protein, trace ketone; negative blood / glucose / bilirubin / urobilinogen; 0-2 rbcs, 11-20 wbcs, many bacteria, no yeast, 0-2 epithelial cells, 0-2 transitional epithelial cells, 0-2 fine granular casts, occasional wbc clumps . 08:55pm blood type-art po2-64* pco2-69* ph-7.40 caltco2-44* base xs-13 . 05:41am blood caltibc-190* hapto-332* ferritn-265* trf-146* . blood wbc-6.4 rbc-3.58* hgb-9.5* hct-30.7* mcv-86 mch-26.6* mchc-31.1 rdw-15.4 plt ct-327 glucose-89 urean-4* creat-0.3* na-146* k-3.7 cl-100 hco3-42* angap-8 . . . . microbiology . urine cultures **final report ** . urine culture (final ): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. warning! this isolate is an extended-spectrum beta-lactamase () producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by -producing species. sensitivities: mic expressed in mcg/ml ________________________________________________________ klebsiella pneumoniae | amikacin-------------- =>64 r ampicillin/sulbactam-- 16 i cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- =>64 r ceftriaxone----------- r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s nitrofurantoin-------- 256 r piperacillin/tazo----- 8 s tobramycin------------ =>16 r trimethoprim/sulfa---- 2 s sputum cultures **final report ** . gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): multiple organisms consistent with oropharyngeal flora. 2+ (1-5 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): sparse growth commensal respiratory flora. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. beta streptococci, not group a. moderate growth. staph aureus coag +. sparse growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations rifampin should not be used alone for therapy. yeast. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s brief hospital course: 51-yo woman with t1-t2 paraplegia, copd, multiple recent admissions for pneumonia, now admitted with hypoxia and fever, altered mental status. . #. hypotension: the patient was admitted with relative hypotension compared to home blood pressures. a right ij cvl was placed in the ed and the patient's pressures did not respond sufficiently to aggressive fluid resuscitation. on admission to the micu unit, a levophed drip was started, more ns was administered and her map and cvp responded. on /, the patient was weaned off levophed. she remained relatively normotensive throughout the remainder of her micu stay, and was eventually transferred to the general medical floors on . the pt. had one episode of severe hypotension to 60mmhg sbp accompanied by altered mental status several days after being transferred to the general medical floor. this occurred after delivering 20 mg of lasix the day prior for severe shortness of breath secondary to pulmonary edema. additionally, the pt's o2 sats dropped to the mid 80's and abg's were performed which showed co2 retention. the pt. was stabilized with fluid boluses and o2 nonrebreather. at this time, her medication list was re-evaluated as it contained multiple centrally acting sedating medications (medication addendum listed below). the pt. was normotensive for the remainder of her stay. . #. hypoxia: pt was admitted with significant hypoxia. right lower lung exam and cxr findings concerning for pneumonia. fever, leukocytosis with neutrophilic predominance, and increased sputum production supportive as well of a pneumonia. sputum notably pink and mucoid in appearance. per recent chest ct, the patient also had some atelectasis and mucoid impaction which likely contributed to her presenting hypoxia. broad spectrum antibiotics, vancomycin and zosyn, were initiated to treat hospital acquired pneumona. on , after persistent hypotension despite treatment, ciprofloxacin was briefly initiated to provide double coverage for pseudomonas. ciprofloxacin was discontinued on the same day after infectious disease consult advised low probablity of success with cipro after zosyn resistance identified. on , zosyn was discontinued as cultures were vancomycin sensitive. chest physical therapy was performed throughout her stay and the patient required oxygen supplementation (4 liter nasal canula)at the time of transfer from the micu. the patient was given 10mg iv lasix on and to diurese the patient after cxr demonstrated evidence of fluid overload. on transfer to the floor, the pt. had oxygen saturations persistently in the low 90's. sputum cultures were mrsa positive, and the pt. was continued on vancomycin. she had an episode of severe respiratory distress several days after transferring to the general medical floors. the pt. had crackles on exam, and she was given 20 mg of lasix to relieve her pulmonary edema. additionally, she was put on o2 nrb, then weaned to 4-5 l nc. the following day, the pt's blood pressure dropped and she experienced aother episode of hypoxia (as outlined above). she was bolused fluids, put on nrb, and weaned to 4l nc. at this time, her medication list was also reevaluated (as above) as her ms/pulmonary performance was waxing and since her return from the micu. after her medication adjustments, the pt's o2 demands slowly improved until discharge where she was doing well breathing room air. . #. altered mental status: patient initially presented with altered mental status thought to be likely toxic-metabolic given infection, hypoxia and hypotension. an abg taken on /201 showed co2 of 56 suggesting carbon dioxide retention and mental status changes secondary to hypercarbia. however, review of records demonstrated chronic hypercarbia with pco2s in 50s-60s. altered mental status largely resolved throughout her stay in the micu. on the general medical floors, the pt. had several issues with waxing/ mental status thought to be a combination of poor ventilation/over sedation with centrally acting medications. adjustments were made to her medication list, and the pt's mental status improved to a consistently interactive state. changes in medications are outlined below: . addendum: pt has been waxing and with her mental status, and has been fluctuating in her ability to maintian oxygen saturations in the 90-92 range, dipping as far as 80%. her medications were reviewed, and with the help of the on-call pharmacist, several changes have been made. her attending dr. is aware and agrees with the medication changes. . previous medication dose..........new medication dose oxybutynin- 10 mg tid ........... discontinued pregabalin- 150 mg tid........... titrated down- new dose 100 mg tid methadone- 5 mg tid .........changed to 5mg -- back to tid baclofen-20mg,10mg,10mg.............10 mg tid . #. uti: patient admitted with a urinalysis concerning for a uti. the patient has a history of urinary tract infections. meropenem was initially withheld as colonization of her urinary tract was presumed and prior infections were zosyn sensitive. while no urinary cultures were positive, meropenem treatment was initiated on as the patient's mental status had some-what worsened despite treatment for pneumonia. the pt. was continued on meropenem throught the duration of her hospitalization, and was discharged on ertapenem to finish her treatment cycle. . #. copd: past medical records demonstrate that the patient may have some component of hypercarbia in setting of copd, with pco2s in the 50s-60s. sedating medications were held as tolerated during the day and the patient was continued on home albuterol and ipratropium. she was counselled on smoking cessation and reports that she has stopped several months prior. during her stay on the general medical floors, the pt had several issues with chronic co2 retention and exaing/ mental status as outlined above. upon discharge, the importance of not smoking was emphasized to the pt. . #. depression: reportedly increased from baseline despite home celexa. patient previously amenable to seeing a psychologist as an outpatient. she was continued on her celexa and social work was consulted and has been following the patient. the patient was continued on her home klonapin dose for anxiety and trazadone was added on as a sleep aid. the pt. was continued on these medications during the rest of her hospital stay. . #. t1-t2 paraplegia with chronic pain: patient maintained on multiple medications at home including baclofen, lidocaine patch, methadone, oxybutynin, pregabalin, trazodone, oxycodone. due to waxing/ mental status, several of her medications were changed (see above addnedum). . #. hypothyroidism - the patient was contined on home levothyroxine. medications on admission: 1. albuterol 0.083% neb soln 1 neb ih q4h:prn dyspnea/hypoxia 2. albuterol-ipratropium puff ih tid 3. baclofen 10 mg po/ng hs 4. baclofen 10 mg po/ng noon 5. baclofen 20 mg po/ng breakfast 6. citalopram hydrobromide 40 mg po/ng daily 7. clonazepam 1 mg po/ng 8. docusate sodium 100 mg po bid 9. levothyroxine sodium 75 mcg po/ng daily 10. lidocaine 5% patch 1 ptch td daily 11. methadone 5 mg po/ng tid 12. oxybutynin 5 mg po noon 13. oxybutynin 10 mg po breakfast 14. oxybutynin 10 mg po hs 15. polyethylene glycol 17 g po/ng daily 16. pregabalin 150 mg po/ng tid 17. sucralfate 1 gm po/ng qid 18. trazodone 100 mg po/ng hs 19. oxycodone (immediate release) 5 mg po tid pain discharge medications: 1. vancomycin 1,000 mg recon soln : one (1) gram intravenous every twelve (12) hours for 3 days. disp:*qs * refills:*0* 2. ertapenem 1 gram recon soln : one (1) gram intravenous once a day for 3 days. disp:*qs * refills:*0* 3. methadone 5 mg tablet : one (1) tablet po tid (3 times a day). 4. pregabalin 75 mg capsule : one (1) capsule po tid (3 times a day). 5. citalopram 20 mg tablet : two (2) tablet po daily (daily). 6. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 7. levothyroxine 75 mcg tablet : one (1) tablet po daily (daily). 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 9. polyethylene glycol 3350 17 gram/dose powder : one (1) po daily (daily). 10. sucralfate 1 gram tablet : one (1) tablet po qid (4 times a day). 11. baclofen 10 mg tablet : one (1) tablet po noon (at noon). 12. baclofen 10 mg tablet : one (1) tablet po hs (at bedtime). 13. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 14. famotidine 20 mg tablet : one (1) tablet po q12h (every 12 hours). 15. bisacodyl 10 mg suppository : one (1) suppository rectal hs (at bedtime) as needed for constipation. 16. clonazepam 1 mg tablet : one (1) tablet po qhs (once a day (at bedtime)) as needed for anxiety / sleep. 17. trazodone 50 mg tablet : 0.5 tablet po hs (at bedtime) as needed for sleep. 18. baclofen 10 mg tablet : one (1) tablet po breakfast (breakfast). 19. oxycodone 5 mg tablet : one (1) tablet po q8h (every 8 hours) as needed for pain. 20. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : two (2) inhalation every 4-6 hours as needed for sob. 21. combivent 18-103 mcg/actuation aerosol : two (2) puffs inhalation tid prn as needed for shortness of breath or wheezing. discharge disposition: home with service facility: vna discharge diagnosis: primary: pneumonia (organism: methicillin resistant staph aureus) urinary tract infection - (organism: extended spectrum betalactamase resistant klebsiella) sepsis (organisms per above) . secondary diagnosis chronic obstructive pulmonary disease paraplegia (lower extremity) chronic pain hypothyroidism anxiety 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: you were hospitalized with a severe pneumonia and urinary tract infection. you developed a condition known as sepsis, and required intensive care in the medical intensive care unit for several days. once you were stable in the intensive care unit, you were sent to the general medical floors to receive continued care as you regained your strength and your infections resolved. you were treated with very strong antibiotics, which you will continue to take outside the hosptial. these drugs are called vancomycin and ertapenem. while you were on the general medical floors, you had issues with your breathing, requiring increased oxygen to breath. in agreement with your primary care doctor, we changed several of your medications that were causing you to be overly sedated, preventing you from breathing well. after the change in medications was made, your clinical status continued to improve. you had installation of a peripherally inserted central catheter (picc line) to allow you to receive antibiotics iv outside the hospital. . several of your home medications have been changed! . previous medication dose..........new medication dose oxybutynin- 10 mg 3x day........... discontinued pregabalin- 150 mg 3x day......... titrated down- new dose 75mg 3x day methadone- 5 mg tid .........changed to 5mg -- back to tid baclofen-20mg,10mg,10mg.............10 mg tid . you will continue to take antibiotics outside the hospital: vancomcyin: ertapenem: followup instructions: department: when: tuesday at 10:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: when: tuesday at 12:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage department: pulmonary function lab when: thursday at 12:10 pm with: pulmonary function lab building: campus: east best parking: garage procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: anemia of other chronic disease other chronic pain urinary tract infection, site not specified congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified acute on chronic diastolic heart failure depressive disorder, not elsewhere classified sepsis other septicemia due to gram-negative organisms personal history of venous thrombosis and embolism other postprocedural status unspecified gastritis and gastroduodenitis, without mention of hemorrhage paraplegia chronic respiratory failure methicillin resistant staphylococcus aureus septicemia methicillin resistant pneumonia due to staphylococcus aureus 

Answer: The patient is high likely exposed to