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: ampicillin / ancef attending: chief complaint: urosepsis, cdiff major surgical or invasive procedure: endotrachial intubation left internal jugular central line placement picc placement x 2 history of present illness: 40 y/o man with h/o c5-quadriplegia, multiple admissions for urosepsis, who presented originally to from rehab 3 days ago with hypotension. he had been found to have esbl uti and c. diff colitis. his infections were initially responding to iv fluids and antibiotics but on he developed increasing abdominal pain and distention. a ct abdomen was done that showed a fluid collection in his right lower abdomen. surgery was consulted and recommended ir-guided drainage. he was then transferred to for ir evaluation. per report, at time of transfer his systolic pressures were 120-130s with hr 50-60s. his mental status was altered (confirmed by his mother and hcp), who said that this is what usually happens when he develops infections. . review of systems is difficult to obtain from patient given that he has altered mental status and is a poor historian. . of note, patient has a complicated urologic history and is followed by dr. . per a recent urology note, patient is "s/p appendicovesicostomy and ace which have not been used in some time due to indwelling foley and rectal tube." past medical history: -c5 quadriplegia -mds -recurrent utis and urosepsis -osa on bipap with settings of at night -seizure disorder -baclofen pump placed by dr. () -cki with baseline cr=1.5 -h/o c diff -h/o bradycardia thought to be secondary to baclofen -depression -s/p appendicovesicostomy -s/p ace- (antegrade continent enema) procedure -s/p right eye prosthesis social history: the patient lives at home with 24 hour care. his mother is very involved but lives out of state. used to work at ups in marketing. had mva at age 17 resulting in quadriplegia. - tobacco:none - alcohol:none - illicits:none family history: father had in 50s. physical exam: vitals: bp 71/32, hr 65, sat 97% general: awakens to voice, disoriented neuro: perseverates on words or phrases, not responsive to simple commands heent: prosthetic right eye, dilated left eye (unchanged per osh records) heart: rrr, normal s1/s2 chest: clear bilaterally anterior fields abdomen: obese, soft, no rebound or guarding; there is a subcutaneous pump in the left lower quadrant; there are surgical incisional scars over the umbilicus and midline extremities: wwp, b/l 2+ lower extremity pitting edema pertinent results: admission labs: 12:31am blood wbc-1.9* rbc-2.79* hgb-8.7* hct-26.1* mcv-94 mch-31.3 mchc-33.5 rdw-21.1* plt ct-27* 12:31am blood pt-11.1 ptt-33.1 inr(pt)-0.9 12:31am blood glucose-106* urean-54* creat-2.3* na-134 k-4.4 cl-104 hco3-17* angap-17 03:48am blood alt-19 ast-24 ld(ldh)-163 alkphos-124 amylase-25 totbili-0.1 12:31am blood calcium-7.6* phos-5.9*# mg-2.1 03:48am blood tsh-8.4* 03:59pm blood free t4-1.0 03:48am blood cortsol-45.2* . discharge labs: 05:40am blood wbc-3.5* rbc-2.83* hgb-8.3* hct-26.4* mcv-93 mch-29.2 mchc-31.3 rdw-20.3* plt ct-484* 05:40am blood glucose-102* urean-27* creat-1.1 na-141 k-5.1 cl-104 hco3-32 angap-10 05:40am blood calcium-8.2* phos-3.9 mg-2.3 05:45am blood phenyto-2.8* . urine studies: 03:04pm urine color-yellow appear-cloudy sp -1.010 10:41am urine color-straw appear-cloudy sp -1.008 03:04pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-lg 10:41am urine blood-mod nitrite-pos protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 10:41am urine hours-random urean-200 creat-17 na-57 k-9 cl-52 02:27am urine hours-random urean-184 creat-45 na-82 10:41am urine osmolal-212 . csf studies: 01:48pm cerebrospinal fluid (csf) wbc-3 rbc-1* polys-0 lymphs-72 monos-28 01:48pm cerebrospinal fluid (csf) totprot-28 glucose-79 01:48pm cerebrospinal fluid (csf) herpes simplex virus pcr-negative microbiology: . mrsa screen: negative blood cultures x 2: no growth blood cultures x 2: no growth blood cultures x 2: no growth urine culture: gram negative rod(s). ~/ml . urine culture: klebsiella pneumoniae. 10,000-100,000 organisms/ml.. warning! this isolate is an extended-spectrum beta-lactamase(esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s meropenem-------------<=0.25 s nitrofurantoin-------- 256 r piperacillin/tazo----- =>128 r tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r . cerebrospinal fluid: gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. viral culture (preliminary): no virus isolated so far. . imaging: . cxr (portable ap) : 1. increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. 2. upper zone redistribution and mild vascular blurring, could reflect mild chf. 3. improvement in parenchymal opacities -- please see comment. . ct pelvis : 1. diffuse colitis with intra-abdominal fat stranding has slightly progressed. 2. contrast passes throughout the large bowel with no extravasation. 3. slight decrease in size of the simple fluid collection in the right iliac fossa which is most likely a locule of free fluid and not typical for an abscess. . ct head w/o contrast : 1. no intracranial hemorrhage or edema. 2. 4.5-mm hyperdense lesion in the midline, at the level of the foramen of , likely a colloid cyst, unchanged over the series of previous cts dating back to . equivocally increased prominence anteriorly of the cavum septum pellucidum, of doubtful significance. . venous ultrasound, left upper extremity : occlusive thrombus in a small segment of the more superficial anterior basilic vein with no flow and no compressibility. brief hospital course: 40 y/o man h/o c5-quadriplegia, recurrent utis and past admissions for urosepsis, transferred from with c. diff colitis, esbl uti, and concern of intra-abdominal abscess. he was initially admitted to the intensive care unit for hypotension. . # esbl urinary tract infection/sepsis: patient was initially septic with hypotension and required pressors in the icu. he was started was treated with meropenem from to (14-day course). as his condition improved, he was weaned off of pressors and transferred to the medical floor. the patient will need to follow up with dr. discharge to evaluate the etiology of his recurrent urinary tract infections. . # c. diff colitis: the patient was treated with po vancomycin and iv flagyl (later changed to po). the plan is to continue flagyl until (one week after other antibiotics were discontinued). vancomycin should be tapered as indicated in the discharge medication list. . # healthcare-associated pneumonia: on , the patient developed fever to 100.2. cxr was concerning for pneumonia. iv vancomycin was added to the patient's other antibiotics on and was discontinued until . the patient needs chest physical therapy. . # abdominal fluid collection: the patient was noted to have an intra-abdominal fluid collection. he was evaluated by the surgical consult service, who felt that the fluid collection did not need to be drained. . # elective intubation: the patient was intubated electively from to for ct abdomen. . # delirium: at baseline, the patient is completely alert and oriented. the patient developed confusion hallucinations following extubation on . psychiatry and neurology were consulted. theh patient's altered mental status was felt to be related to delirium in the setting of infection and medications. lp was unremarkable. the was no evidence of seizures. the patient continued keppra and dilantin (pre-admission medications), and was briefly on haloperidol. haloperidol was stopped on . the patient's mental status gradually improved, and he was back to his baseline (normal mental status) at the time of discharge. . # seizures: the patient continued keppra and phenytoin. neurology was consulted. the patient was discharged on keppra 1000 mg . phenytoin was dosed at 150 mg qam and 200 mg qpm. the patient will need to have a phenytoin level checked on . the goal level is . neurology follow-up with dr. was arranged. # dysphagia: as the patient's mental status improved, he was evaluated by video fluoroscopy. this showed mild oropharyngeal dysphagia characterized primarily by intermittent premature spillover and swallow delay resulting in silent aspiration of thin liquids before and during the swallow. cued cough was weak/breathy and ineffective in clearing aspirated material from the trachea. the use of a chin tuck (single sips and consecutive straw sips) was effective in preventing and eliminating aspiration of thin liquids. however when patient was noted to aspirate thin liquids when attempting to self-feed straw sips of thin liquid reduced coordination resulting in poor chin tuck position. the speech and swallow service recommended a po diet of thin liquids and regular solids. the patient will require strict 1:1 supervision to assist with feeding and cue him to use a chin tuck with all sips of thin liquids. if patient attempts to self-feed he should be downgraded to nectar thick liquids. the patient should undergo continued monitoring at rehab and repeat instrumental evaluation once he appears at his baseline and may be more able to protect his airway despite swallow delay. . # acute kidney injury: the patient's creatinine peaked at 2.5. this was felt to be prerenal. the patient was treated with iv fluids. his creatinine was 1.1 at the time of discharge. . # pancytopenia. the patient presented with wbc 1.9, hct 26, plt 27. he has a known history of myelodysplastic syndrome. review of records shows that he has developed similar pancytopenia in the setting of acute illnesses (previously during admissions in , , and ). he received 2u prbc in the icu. at the time of discharge, the patient had wbc 3.5, hct 26, and plt 484. the patient's cbc should be followed 2 times weekly after discharge. . # s/p appendicovesicostomy/ace- (anterograde continence enema): the patient is followed by dr. (urology) as an outpatient. he has an appendicovesicostomy (leading to the bladder), and and ace- (leading to the colon). the patient needs urinary catheterization times daily through his appendicovesicostomy (6a/12p/6p/12a), using 8fr straight catheter (at umbilicus, patient left side). procedure: (sterile technique) cleanse bladder ostomy area with chloraprep; lubricate catheter tip and insert catheter a few inches (does not need to be inserted the whole length & you may pull back if no flash of urine once fully inserted); attach catheter end to urinary leg bag collection bag to capture drainage (drain approx 30 mins); remove catheter, cover ostomy with sterile 2x2, and apply tegaderm. additionally, the patient requires straight urethral catheterization three times weekly (monday, wednesday, friday) to remove sediment. the patient does not currently need continence enemas through his ace- (leading to the colon). however, the ace- needs to be accessed 1-2 times daily to prevent the tract from closing up. . # hypertension: metoprolol was started due to hypertension after extubation. however, the patient was noted to be bradycardic to as low as 48 on metoprolol 25 mg tid. on review of past medical records, it became apparent that the patient had had problems with bradycardia and long pauses during a recent admission. therefore, metoprolol was stopped at the time of discharge. . # depression: sertraline was initially held. this was restarted at 50 mg daily at the time of discharge. consideration can be given to further titration of the patient's sertraline dose (his pre-admission dose was 100 mg daily). . # obstructive sleep apnea: cpap at night. . # communication. mother at . # code status: okay to intubate, do not resuscitate. medications on admission: medications (at time of transfer from ): - keppra 1000 mg - flagyl 500 mg iv q8h - dilantin 100 mg iv bid - ertapenem 1 g iv q24h - sertraline 100 mg daily - lactobacillus nebs around-the-clock . medications (per recent discharge summary ): - acetaminophen 325-650 q6h prn - albuterol nebs - vitamin b12 500 mcg daily - flucinolone 0.01% cream prn - ipratropium nebs q6h - keppra 1000 mg - levofloxacin / flagyl - dilantin 100 mg - sertraline 100 mg qday - simvastatin 40 mg qday discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 2. phenytoin 50 mg tablet, chewable sig: three (3) tablet, chewable po qam (once a day (in the morning)). 3. phenytoin 50 mg tablet, chewable sig: four (4) tablet, chewable po qpm (once a day (in the evening)). 4. sertraline 50 mg tablet sig: one (1) tablet po once a day. 5. vancomycin taper vancomycin liquid 250 mg four times daily from ; vancomycin liquid 125 mg four times daily from ; vancomycin liquid 125 mg twice daily from ; vancomycin liquid 125 mg once daily from . 6. baclofen pump baclofen *nf* 1700.2 mcg/day intrathecal infusion concentration: 4000mcg/ml 7. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units subcutaneous injection tid (3 times a day). 8. metronidazole 500 mg tablet sig: one (1) tablet po every eight (8) hours for 5 days: last day = . 9. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 10. simvastatin 40 mg tablet sig: one (1) tablet po at bedtime. 11. vitamin b-12 500 mcg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: discharge diagnosis: primary: -esbl klebsiella uti, complicated by sepsis -clostridium difficile -delirium -health-care associated pneumonia -acute on chornic kidney injury -dysphagia . secondary: -c5 quadriplegia -s/p ace- -s/p appendicovesicostomy -seizure disorder discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: you were admitted to with a urinary tract infection, colitis from clostridium difficile, and a fluid collection in your abdomen. you were treated with antibiotics. the surgical consult service was consulted due to the fluid collection in your abdomen, and they felt that no invasive intervention was required. . you were admitted to the intensive care unit, where you initially required medications to support your blood pressure. you were electively intubated for a ct scan. . your hospital course was complicated by pneumonia, which was treated by antibiotics. you also developed confusion, which was felt to be related to infection and had resolved by the time of discharge. . there are some changes to your medications: start flagyl 500 mg every 8 hours for 5 more days start vancomycin taper change phenytoin dose to 150 mg in the morning and 200 mg in the evening decrease sertraline to 50 mg daily. talk to your doctors about increasing this to your previous dose of 100 mg daily. . you had a high-normal potassium level and a mildly low white blood cell count at the time of discharge. you should have a complete blood count and chemistry panel (chem 7) checked twice weekly after discharge. . you will need to have your phenytoin (dilantin) levels followed closely. followup instructions: specialty: urology dr. date and time: at 2:30 p.m. phone number: location: . department: neurology when: wednesday at 1 pm with: drs. & building: sc clinical ctr campus: east best parking: garage . make an appointment to see your primary care doctor after you leave rehab. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung insertion of endotracheal tube enteral infusion of concentrated nutritional substances diagnoses: pneumonia, organism unspecified acidosis obstructive sleep apnea (adult)(pediatric) urinary tract infection, site not specified acute kidney failure, unspecified severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified depressive disorder, not elsewhere classified chronic kidney disease, unspecified acute respiratory failure septic shock intestinal infection due to clostridium difficile other septicemia due to gram-negative organisms epilepsy, unspecified, without mention of intractable epilepsy quadriplegia, unspecified 

Answer: The patient is high likely exposed to