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: codeine / cephalosporins attending: chief complaint: fever major surgical or invasive procedure: right subclavian central line placement history of present illness: 62 yo woman with h/o of cervical ca s/p tah and xrt complicated by radiation cystitis recquiring straight cathing, s/p colectomy and sb resection, and h/o of ureteral obstructions recquiring stent placement, presents today with fever, flank pain and abdominal discomfort. . per records had recent fall after tripping over vacuum cord and broke wrist and had cast placed, which is making self-cathing difficult. she also notes that her right abdomen is sore agian, which it becomes when she has these utis. of note she had change in right ureteral stent 3weeks ago, complicated by uti. yestrday while she was starting her tpn for short gut syndrome she noticed she was febrile. they stopped the tpn, flushed her picc line which has been in place since and then restarted the infusion and still felt like spiking temp and came in for evalautaion. . in ed, arrived bp 60/40 and t 103, but mentating and recieved 9lns, started on dopa peripherally as refused sepsis/central line and had ct scan of abdomen which was unchanged from last ct scan 3 weeks ago. given levoquin and vanc x1. cast was bivalaved to help with her pain. also with intermitent fleeting cp with burping sensation and hypoxic to 91%2l. repeat cxr with bilateral infiltrates at bases with increased vascular congestion, ct scan with no real change from few weeks ago with continued minimal ascites, but otherwise nothing significant, perirenal cyst. . since arrival here now has 2/4 bottles with gnr, on 10mcg of dopa and continuous fluids at 200cc/hr. past medical history: 1. cervical ca-- s/p hysterectomy , recurrence , xrt, c/b entero-vaginal fistula s/p colectomy and partial small bowel resection 2. short gut syndrome s/p hickman catheter and picc for tpn 3.hx multiple admissions, caused by: enterococcus, klebsiella, parapsilosis, etc.( thought to be from bladder and stool) 4.dvt secondary to multiple central lines 5.radiation cystitis, requiring self-straight catheterization 8 times per day 6.recurrent utis, responding to ciprofloxacin; chronically colonized with yeast 7.right ureteral stenosis s/p stent placement, requiring multiple revisions 8.osteoporosis 9. hypothyroidism ?????? not currently on hormone replacement, last tsh=1.9 in . migraine headaches 11.depression 12.fibromyalgia 13.chronic abdominal pain secondary to multiple surgeries, adhesions, and radiation, on stable doses of pain regimen. social history: lives with husband in , ma. her husband is very involved in her care. no alcohol or tobacco. family history: mother died of brain ca and father died on mi early physical exam: vs: t101.9 p 110 bp 72/42 rr 26 sat 94%on 6lnc gen: aao, nad heent: perrl, mmm, clear op cv: rrr, tachy no murmurs lungs: ctab with bilateral crackles at bases back: + left cvat no right cvat abd: soft, +epigastric tenderness, +bs ext: no edema, 2+dp pulses, left picc in place w/o erythema brief hospital course: sepsis: the patient presented with decreased blood pressure, tachycardia, fever, and signs of distributive shock. she was admitted to the icu. she was found to have gnr in bottles thought initially to be more consistent with urosepsis. she was supported for a short period of time on pressors and then weaned off. she received approximately 14l of fluid for pressure support. on review of cultures, she grew two types of gnr in her blood, nothing from her catheter tip, and enterococcus in her urine. before sensitivities were known, antibiotics were started emperically based on past sensitivities. she most recently had enterococcus which was res to lev, but amp and vanc , was treated with amp iv for her uti. she had also had burkolderia/pseudomonas in , which was ceftaz resistant, but meropenum sensitive and hx of klebsiella pan senstive infectoin 1yr ago. therefore, she was initiated on meropenem as well to treat her gnr sepsis. the urology service was consulted to assess stents and possiblity of stent infections. their perspective was that the stent did not need intervention. stim test showed no adrenal insufficiency. in the meantime, culture sensitivities and id returned. . at this point, the patient was tx to the floor for further management as she had stabilized in the icu. the patient was being appropriately treated with ampicillin for her uti. her gnr bacteremia was identified as two types of enterobacter, both of which were sensitive to levoquin. therefore, meropenem was discontinued and levoquin was initiated with a plan to treat for 14 days after cultures were negative. cultures were taken daily for surveillance and remained negative after the first day in the hospital. the patient had had a subclavian line placed for access after her picc was removed. this remained in place without sign of infection until her final day of hospitalization, when it was removed after ir placed a picc line. the patient had expressed her preference for a hickmann line, but this was thought to carry an increased risk in the time immediately after her infection. it was decided that she would have a picc placed (double lumen) for one month and she could have a hickmann placed thereafter. she has had numerous line infections in the past and a surgical line was to be avoided until she had proved that this infection was cleared successfully. she was continued on her home regimen of 0.5mg of coumadin per day with the thought that it may prevent line clots as she has a history of line clot in the past. inr remained at 1, and the patient was also started on heparin prophylaxis during her stay at the hospital. . arf: the patient presented with an elevated creatinine. it was thought to be due to dehydration and sepsis physiology. as the patient was hydrated, and as the sepsis physiology resolved, the creatinine stablized and then resolved. . hypoxia: in the icu, the patient exhibited some hypoxia. it was thought likley to be related to fluid overload, though initially pna and atelectasis were entertained as well. x ray revealed fluid overload, and as the patient's status improved and she cleared her infection, her pressures returned and she began to auto-diurese. she was net negative 2-3l per day each day for 5-6 days after transfer to the floor and her symptoms of sob and hypoxia resolved. . metabolic acidosis: on presentation, the patient had both gap and non-gap acidosis, likely realted to sepsis and lactate (gap acidosis), with arf and underlying short gut syndrome and acid losses from ostomy output (non-gap acidosis). the patient was monitored closely. her lactic acidosis corrected quickly and the non-gap acidosis also corrected, albeit far more slowly, as the patient's health improved. . short gut: the patient has a long history of short gut syndrome caused by colectomy after radiation to her abdomen for recurrant cervical cancer years ago. this remained stable at this hospitalization. the patient initially had her tpn held as she did not have central access for a number of hours in the icu. once a subclavian line was placed, tpn was restarted and the patient received tpn through this line until the last day of hospitalization when the subclavian was removed after a picc was placed by ir. the plan was to continue her tpn through the picc for one month, whereupon it could be changed to a hickmann catheter for comfort if the patient so desired. . wrist fracture: the patient presented with a short cast on her left arm after a fall at home (see hpi). orthopedics was consulted to evaluate the patient. the cast was removed and replaced with a longer cast to improve alignment. the longer cast was left in place for 3 days and replaced, again, with a short cast after better alignment was confirmed radiographically. the patient complained of decreased mobility with the cast, and the orthopedic service was careful to leave her as much flexibility in her hand as possible, however she was still unable to manipulate her ostomy bag or to self cath after the new short cast was in place. she was seen by pt and found to be mobile and ready for discharge from their perspective. she was seen by ot, who suggested a short rehab stay to ensure that she could conduct her self care after hospitalization discharge. she was instructed to follow up with dr. at orthopedics 2 weeks after discharge for x-rays and re-evaluation of her fracture. . ## preventive antibiotics - the idea of preventive antibiotics in this patient with a history of numerous line infections who is dependent on tpn for nutrition was raised repeatedly at this hospitalization. however, the patient has been evaluated by id as an outpatient numerous times in the past and preventive antibiotics was repeatedly rejected as it tends to prevent infections for a few months and then selects for resistant strains. . ## pain control - pt has complicated pain regimen at home for fibromyalgia and her arm pain. at home, she is on methadone 5 tid, oxycontin 20 , and percoset for breakthrough pain. in addition, she has numerous non-narcotic pain medications. at this hospitalization, her non-narcotic pain regimen was continued, but her narcotics were streamlined to include methadone 5mg tid and msir for breakthrough pain. this was to be continued as an outpatient as she had good pain control. . ## anemia: iron was found to be low, ferritin was wnl, but given her sepsis, it would have been expected to be very high. tibc was low. these labs suggest both iron deficiency and anemia of chronic dz. iron was increased in her tpn as described below. . fen: the patient eats a full diet at home and receives tpn without fat. at home she receives 5mg of iron in her tpn. she was found to be very iron deficient at this hospitalization and her iron was increased to 10mg each night. tpn was cycled over 10 hours and electrolytes were managed as they are at home. at the time of discharge, her tpn was stable and similar in content to her prior formulation with the exception of the increased iron content. medications on admission: mobic 7.5 mg qd xanax 0.5mg qhs prtonix 40mg qd flexeril 10mg qhs coumadin 0.5mg qhs nystatin qhs prozac 40mg qam salagen 5mg tid methadone 5mg tid vitmain d vivelle 0.375patch qweek b12 1000units qmonth aredia q3mos pridium prn fiorecet prn percocet prn zofran prn ativan 1mg tid prn neurotnin 300mg tid oxycontin 20mg q12hrs discharge medications: 1. acetaminophen-caff-butalbital mg tablet sig: tablets po q4-6h (every 4 to 6 hours) as needed for headache. 2. methadone 5 mg tablet sig: one (1) tablet po tid (3 times a day). 3. fluoxetine 20 mg capsule sig: one (1) capsule po bid (2 times a day). 4. pilocarpine hcl 5 mg tablet sig: one (1) tablet po tid (). 5. alprazolam 0.25 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)) as needed. 6. warfarin sodium 1 mg tablet sig: 0.5 tablet po hs (at bedtime). 7. olopatadine 0.1 % drops sig: two (2) drop ophthalmic (2 times a day) as needed. 8. cyclobenzaprine 10 mg tablet sig: one (1) tablet po tid (3 times a day). 9. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 10. vivelle 0.0375 mg/24 hr patch biweekly sig: one (1) patch transdermal once a week. 11. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days: take as instructed until finished with tablets. disp:*4 tablet(s)* refills:*0* 12. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed: use as directed for itching. disp:*1 bottle* refills:*0* 14. zofran 4 mg tablet sig: 1-2 tablets po twice a day. 15. vitamin b12-vitamin b1 100-1 mg/ml solution intramuscular 16. aredia 30 mg recon soln sig: one (1) infusion intravenous q 3 mo: as instructed by physician. 17. neurontin 300 mg capsule sig: one (1) capsule po three times a day. 18. outpatient lab work chem 7 and cbc weekly 19. tpn non-standard tpn: volume 1000 (ml/day amino acid 50 (g/d) branched-chain aa 0 (g/d) dextrose100 (g/d)fat 0(g/d) standard adult multivitamins nacl 90 naac 30 napo4 0 kcl 15 kac 0 kpo4 10 mgs04 10 cagluc 10 heparin(units) 4000 iron 10mg cycle over 10 hrs. start at 1800 (6 pm) stop at 0400 (4 am) plug and flush line 20. picc line iv flush sodium chloride 0.9% flush 3 ml iv qd picc 21. morphine 15 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 22. pilocarpine hcl 5 mg tablet sig: one (1) tablet po qid (). 23. ampicillin sodium 2 g recon soln sig: one (1) gram injection q6h (every 6 hours) for 4 days. 24. aredia 30 mg recon soln sig: one (1) dose intravenous q 3 months. discharge disposition: extended care facility: & rehab center - discharge diagnosis: bacteremia with sepsis complicated by arf uti wrist fracture that was reset secondary diagnoses: osteoporosis hypothyroidism ?????? not currently on hormone replacement, last tsh=1.9 in migraine headaches depression fibromyalgia chronic abdominal pain secondary to multiple surgeries, adhesions, and radiation, on stable doses of pain regimen. discharge condition: stable - afebrile, blood cx ngtd since day after admission. stable baseline chronic pain. discharge instructions: you were admitted with a urinary tract infection and two kinds of bacteria in your blood. these were both serious infections that required a stay in the icu. complicating this, you had the recent fracture of your arm. you were treated with antibiotics and recasting to align your arm better. . you will need to see your primary care physician weeks for a follow-up appointment for lab work and a check-up. . you should follow up with dr. in orthopedics for cast removal and a check-up within 2 weeks. call dr. office at ( to schedule an appointment. . if you develop fever or chills, or severe n/v, or if you have increasing abd pain or pain with urination, if you lose consciousness or feel as though you might, or if you have any other worrisome symptoms, you should seek immediate medical attention. followup instructions: pcp 1-2 weeks. will need chem 7 and cbc. will need checkup with attention to pain, monitoring for c dif (given recent abx), self-cath technique. . ortho for cast removal/check up. call dr. office at ( to schedule an appointment. . provider: , m.d. where: phone: date/time: 3:20 provider: , md where: lm phone: date/time: 1:00 provider: , m.d. where: center phone: date/time: 2:45 md, procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances infusion of vasopressor agent diagnoses: acidosis acute kidney failure, unspecified severe sepsis unspecified acquired hypothyroidism osteoporosis, unspecified septic shock iron deficiency anemia, unspecified other septicemia due to gram-negative organisms other and unspecified postsurgical nonabsorption myalgia and myositis, unspecified personal history of malignant neoplasm of cervix uteri irradiation cystitis late effect of radiation aftercare for healing traumatic fracture of other bone 

Answer: The patient is high likely exposed to