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: penicillins / erythromycin base / keflex / sulfa (sulfonamide antibiotics) / compazine / valium / fentanyl / flecainide / tape "x10yd / midodrine / topamax / clindamycin / ferrlecit / linezolid / levaquin in d5w / vancomycin / ciprofloxacin / avelox / droperidol / nut flavor / peanut / epinephrine / shellfish attending: chief complaint: hypotension, altered mental status major surgical or invasive procedure: removal of tunneled line placement of picc line history of present illness: 36 yo f w/ h/o neuropathic dysautonomia on fludrocortisone at home, bacterial overgrowth syndrome, and hypothyroidism, who presents with hypotension and altered mental status. per health care proxy, patient was in usoh on . went for dental cleaning that morning after taking azithromycin (also took a dose post-procedure) and during procedure received xylocaine, subsequently became hypertensive and tachycardic. was sent to ed where received a beta blocker with some response in hr. discharged home and was tachy to 150s, which improved after a 1 l ns bolus (of note, patient typically gets 1l ns w/ k at home daily). patient "felt crappy" but without focal complaints, but improved after fluids. later in night continued to feel abnormal, and went to bathroom with cramping and loose stools. no noted. was dizzy and felt pre-syncopal in bathroom and per hcp had a brief syncopal episode w/ loc of about 1 sec. recovered and was agitated but oriented. was brought to ed given refractory hypotension and concern for sepsis. . in the ed, initial vs were: hr70 bp72/27 rr12 o2 sat 100%. patient triggered on arrival for hypotension and was given 1l ns w/ mild improvement of her pressure. she complained of head and ear pain (per hcp these are typical symptoms for her when she is septic) as well as muscle cramps. she was also noted to be somewhat drowsy and confused. pt and hcp reported these are typical symptoms for her when septic and refused lp w/o sedation. she received a total of 4l of ns bringing her pressures to 90s systolically. she was started on levophed for additional support as well as gentamicin and daptomycin for empiric coverage given her multiple allergies. she was also give 80 meq k for potassium of 2.0 on arrival, toradol 30 mg iv x2, and zofran. given report of increased abdominal discomfort and diarrhea, she underwent ct abd/pelvis and ruq u/s w/o focal findings. . on arrival to the icu, patient was somnolent and not following commands. . review of systems: (+) unable to obtain secondary to patient's mental status. past medical history: 1. postural orthostatic tachycardia : longstanding, gives self ivf boluses 5 days a week, given over 2 hours depending on dose of florinef taken that day. she says her baseline hr is usually in the 120's. 2. hypokalemia: requires potassium in ivf 3. tachycardia induced cardiomyopathy: most recent echo with ef 45-50% and mild lv global hypokinesis with no valve abnormalities. 4. recurrent sinusitis. 5. hypothyroidism. 6. hypoglycemia - says episodes come at random, not medicated. 7. status post three laminectomies as a child. 8. anorexia nervosa: reports not active. 9. history of enterococcal (vanc susceptible) sepsis, coag negative staph, and non-fermenter, nonpseudomonas infections related to hickmann catheter. 10. gerd: hiatal hernia on most recent egd on , reflux to level of vocal cords. 11. status post-appendectomy. 12. congenital strabismus. 13. hyperprolactinemia and pituitary adenoma by mri. 14. depression. 15. post-traumatic stress disorder. 16. history of cns sepsis . 17. history of anemia. 18. cns sepsis in . 19. serratia hickman line infection on the left (only wound culture not culture was positive) 20. abdominal wall discoloration with distention/lipi dystrophy and livedo reticularis. 21. bacterial overgrowth syndrome- takes rifaximin at times social history: disabled due to pots, stays at home with pca. denies tobacco, etoh use, no ivdu or illicit substances. family history: grandfather (maternal) had pheochromocytoma and autonomic dysfunction similar to her syndrome. grandfather had pheochromocytoma and coronary artery disease. a maternal grandmother had lung cancer. there was breast cancer in a maternal grandmother and aunt. there is hypothyroidism in the family. physical exam: phyisical exam on admission: vitals: t:99.1 bp: 100/69 p: 104 r: 16 o2: 99% on ra general: thin, chronically ill appearing woman, somnolent, moaning to verbal stimuli, but not following commands heent: r pupil 2 mm and reactive, l pupil 4 mm and reactive; sclera anicteric neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally anteriorly, no wheezes, rales, rhonchi cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, diffusely tender (grimaces when palpate), non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 02:52am wbc-1.3*# rbc-2.91*# hgb-9.8*# hct-27.4*# mcv-94 mch-33.6* mchc-35.7* rdw-12.4 02:52am neuts-80.0* lymphs-15.7* monos-2.1 eos-1.9 basos-0.2 02:52am albumin-2.3* calcium-5.6* phosphate-1.5* magnesium-1.1* 02:52am lipase-27 02:52am alt(sgpt)-19 ast(sgot)-28 alk phos-35 tot bili-0.7 02:55am hgb-9.8* calchct-29 02:55am glucose-86 lactate-2.5* k+-2.2* 03:44am ret aut-1.4 03:44am pt-17.4* inr(pt)-1.6* 03:44am wbc-1.5* rbc-3.63* hgb-12.2 hct-34.1* mcv-94 mch-33.5* mchc-35.7* rdw-12.4 03:44am neuts-79* bands-1 lymphs-15* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 03:44am glucose-93 urea n-9 creat-0.8 sodium-142 potassium-3.4 chloride-113* total co2-18* anion gap-14 03:51am glucose-88 lactate-3.7* k+-3.5 11:29am cortisol-30.7* 04:15am urine -neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-tr 04:15am urine rbc-1 wbc-<1 bacteria-few yeast-none epi-0 04:15am urine hyaline-14* 04:15am urine mucous-rare . micro . 4:20 am culture from central line. culture, routine (preliminary): gram negative rod(s). preliminary sensitivity. these preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. check for final susceptibility results in 24 hours. staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. sensitivities: mic expressed in mcg/ml _________________________________________________________ gram negative rod(s) | ceftazidime----------- s ciprofloxacin--------- s piperacillin/tazo----- s tobramycin------------ s aerobic bottle gram stain (final ): gram negative rod(s). reported to and read back by on @ 520 pm. anaerobic bottle gram stain (final ): gram positive cocci in clusters. reported to and read back by @ 9:00 am. 4:15 am culture from central line. culture, routine (preliminary): gram negative rod(s). identification and sensitivities performed on culture # 329-0551m . aerobic bottle gram stain (final ): gram negative rod(s). reported to and read back by on @ 520 pm. 4:15 am urine site: not specified chm s# m ucu added . **final report ** urine culture (final ): hafnia alvei. >100,000 organisms/ml.. hematology/chemistry specimen, possibly contaminated. interpret results with caution. piperacillin/tazobactam sensitivity testing available on request. escherichia coli. 10,000-100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ hafnia alvei | escherichia coli | | ampicillin------------ 4 r 4 s ampicillin/sulbactam-- 4 r 4 s cefazolin------------- =>64 r <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- 4 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s levofloxacin----------<=0.12 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- <=16 s 32 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s 11:42 pm stool consistency: not applicable source: stool. fecal culture (pending): campylobacter culture (pending): ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (pending): fecal culture - r/o e.coli 0157:h7 (pending): clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 4:57 am culture source: line-cvc. culture, routine (pending 10:32 pm stool consistency: soft source: stool. **final report ** ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. . imaging . cxr : findings: ap and lateral chest radiographs were obtained. the lungs are clear with no evidence of consolidation. no effusion or pneumothorax is present. blunting of the right costophrenic angle and hemidiaphragm elevation are chronic and unchanged. no effusion or pneumothorax is present. a left subclavian line terminates at the low svc. the heart and mediastinal contours are normal. impression: no acute cardiopulmonary process. . ct head : findings: no acute intracranial hemorrhage, edema, or mass effect is present. the ventricles and sulci are normal in size and configuration. the basal cisterns are not compressed. the visualized paranasal sinuses and mastoid air cells are well aerated. impression: no evidence of an acute intracranial process . ct abdomen/pelvis : findings: the visualized lung bases are free of nodules, consolidations, or effusions. the liver has a heterogeneous appearance. diffuse periportal edema is present. small amount of perihepatic ascites is seen. there is a large amount of pericholecystic fluid which collapses the gallbladder lumen centrally. no intra- or extra-hepatic biliary dilatation is seen. the main portal vein and branches are patent. the ivc is distended. the pancreas, spleen, and adrenal glands are normal. the kidneys enhance and excrete contrast symmetrically. no mesenteric or retroperitoneal adenopathy is present. the stomach, small and large bowel are of normal caliber and appearance. pelvis: the remainder of bowel is unremarkable, the appendix is not visualized, there are no secondary signs of appendicitis. the bladder and uterus are normal. bone windows: there are no concerning lytic or sclerotic lesions. impression: diffuse periportal edema, perihepatic ascites and pericholecystic fluid most consistent with recent aggressive fluid resuscitation; however, right upper quadrant ultrasound can be performed to confirm these findings. . ruq us : indication: 66-year-old woman with abdominal pain and abnormal ct, question cholecystitis. findings: limited ultrasound was performed of the right upper quadrant. the liver has a homogeneous echotexture with no focal lesions identified. the main portal vein is patent. the gallbladder wall is markedly edematous, measuring a maximum of 1.4 cm, compressing the gallbladder lumen. no stones are identified. the common bile duct is normal in caliber measuring 3 mm. negative son sign. impression: massive gallbladder wall edema, which compresses the gallbladder lumen, likely secondary to vigorous volume resuscitation. . elbow x-ray : indication: dog bite six days ago complicated by septic shock. three views of the left elbow are normal. there is no fracture, effusion, bony destruction or dislocation. there is no definite soft tissue mass or fluid collection. discharge labs: 02:04pm wbc-5.6 rbc-3.27* hgb-10.8* hct-29.7* mcv-91 plt ct-249# 05:49am glucose-82 urean-6 creat-0.6 na-140 k-3.4 cl-106 hco3-28 05:49am phos-3.5 mg-2.1 brief hospital course: 36 year old woman w/ h/o neuropathic dysautonomia, bacterial overgrowth syndrome, and hypothyroidism presenting with hypotension and altered mental status concerning for sepsis and found to be bacteremic with pseudamonas long term central line infection. of note, team communicated closely with patient's outpatient providers thoughout the hospital stay. # septic shock- patient w/ pots with baseline sbps in the 90s-100s as well as diarrhea and also with altered mental status. remained hypotensive despite aggressive fluid boluses and required pressor support with levophed for approximately 24 hours. in the icu she was fluid resuscitated further. her lactate trended down and pressure normalized. given patient is on chronic steroids at home, considered adrenal insufficiency contributing to hypotension. stim stest was performed and was normal. sources of infection considered were pulmonary, abdominal, urinary, central line (in for 1 year as patient self administers normal saline daily at home), cns given ams, and oral in the setting of recent dental work. also, patient gave history of recent dog bite on her left elbow. in ed, patient was broadly covered with antibiotics with daptomycin/gentamycin given extensive allergies to multiple antibiotics. infectious disease team was following closely. patient was continued on daptomycin/gentamycin and doxycycline/flagyl were added because of concern for dental infection as well as concern for pasturella in the setting of recent dog bite. source of infection was investigated. in setting of diarrhea, obtained ct abdomen/pelvis and ruq us as well as sent stool cultures for o&p, vibrio, yirsinia, campylobacter, c.dif all of which were negative and did not demonstrate a source of infection. cxr with no pneumonia. x-ray of the left elbow did not show any abnormality dog bite. urine cultures grew out pan sensitive e. coli as well as hafnia alvei resistant only to ampicillin and cefazolin. cultures grew out pseudomonas sensitive to cefazadime, ciproflox, zosyn, gentamycin, tobramycin. two days into hospital stay, area surrounding patient's central line (in for 1 year) became erythematous and tender. decision was made to remove the line as this was the likely nidus of infection. new picc was placed instead. shortly after removal of line, patient's condition improved. she was changed from gentamycin to tobramycin given shortage of gentamycin. she will complete a total of two weeks of gentamycin, dated since the removal of her central line, to be completed on . # altered mental status- differential included included secondary change from septic picture vs. primary cns process such as meningitis or encephelitis. ct head was negative for acute process. as hypotension resolved, mental status returned to normal and thus lumbar puncture was deferred. # pancytopenia- likely secondary to septic picture particularly given rapid development of leukopenia and thrombocytopenia compared to normal values on . does have a slight anemia compared to recent baseline in 40s, though true baseline is unclear. fdps were mildly elevated, but fibrinogen/d-dimer wnl not indicative of active dic. baseline unclear, but in mid 30s to 40s. most recently was 47.6 in clinic on and currently 34.1. no signs of active bleeding on exam. stool was guaic negative. did not require transfusion. hct stabilized at 30 and platelets returned to . # pots- long history of autonomic dysregulation which has been treated with gabapentin and fluorinef. has baseline bps in 90s-110s and hr in 90s-100s. patient was continued on her home florinef; stim was negative as noted above. initially held home gabapentin and ritalin in setting of sepsis and altered mental status, but re-started them once patient improved. # diarrhea: worsened several days into antibiotic therapy; thought to be antibiotic associated diarrhea. all stool cultures negative, as well as a stool pcr for c.difficile. her diarrhea resolved with increasing her dose of immodium. she was also given a five day course of rifaximin. she was seen in consultation by the gi service, and should continue to follow-up with dr. as an outpatient. # hypokalemia: is a chronic issue for the patient. she was repleted on a once-to-twice daily basis over the last several days of her hospitalization, and is being discharged with orders for ns with 50 meq of potassium, as she has taken in the past. her electrolytes will be re-checked daily for two days following discharge, then again two days later. subsequent need for electrolyte checks to be determined by her pcp at her visit on . medications on admission: amphetamine-dextroamphetamine - 30 mg tablet - 1 (one) tablet(s) by mouth twice a day - no substitution amphetamine-dextroamphetamine - 10 mg tablet - 1 tablet(s) by mouth three times a day - no substitution azithromycin - 500 mg tablet - 1 tablet(s) by mouth 1/2 hour prior to procedure azithromycin - 500 mg recon soln - 500 mg iv 1/2 hour prior to procedure chlorzoxazone - (per old records) - 500 mg tablet - 1 tablet(s) by mouth twice a day as needed for neck pain clobetasol - 0.05 % cream - apply affected areas twice a day do not use on face or folds epinephrine - 0.15 mg/0.3 ml (1:2,000) pen injector - use as directed for anphylaxis as directed disp 1 2-pack ergocalciferol (vitamin d2) - 50,000 unit capsule - 1 capsule(s) by mouth monthly fludrocortisone - (dose adjustment - no new rx) - 0.1 mg tablet - 2 tablet(s) by mouth twice a day gabapentin - 800 mg tablet - 1 tablet(s) by mouth three times a day i.v fluids - (dose adjustment - no new rx) - - 50 meq potassium added levothyroxine - 112 mcg tablet - 1 (one) tablet(s) by mouth once a day - no substitution lidocaine - 5 % (700 mg/patch) adhesive patch, medicated - topically for 12 hours as needed for pain liothyronine - 5 mcg tablet - 1 tablet(s) by mouth once a day ondansetron hcl - 8 mg tablet - 1 tablet(s) by mouth once a day as needed for nausea rabeprazole - (per old records) - 20 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth twice a day sodium fluoride-pot nitrate - 1.1 %-5 % paste - use as directed twice a day . medications - otc cetirizine - 10 mg tablet - 1 tablet(s) by mouth once a day ranitidine hcl - (otc) - 150 mg capsule - 1 capsule(s) by mouth once a day allergies: avelox, ciprofloxacin, clindamycin, compazine, erythromycin base, fentanyl, ferrlecit, flecainide, keflex, levaquin in d5w, linezolid, midodrine, nut flavor, peanut, penicillins, sulfa (sulfonamide antibiotics), tape "x10yd, topamax, vancomycin, droperidol, valium, epinephrine discharge medications: 1. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 2. liothyronine 5 mcg tablet sig: one (1) tablet po daily (daily). 3. fludrocortisone 0.1 mg tablet sig: two (2) tablet po bid (2 times a day). 4. gabapentin 400 mg capsule sig: two (2) capsule po q8h (every 8 hours). 5. chlorzoxazone 500 mg tablet sig: one (1) tablet po bid prn () as needed for neck pain. 6. lidocaine-prilocaine 2.5-2.5 % cream sig: one (1) appl topical prn (as needed) as needed for muscle pain. 7. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 8. dextroamphetamine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 9. dicyclomine 10 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*1 month's supply* refills:*0* 10. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for nausea, stomach upset. 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 12. loperamide 2 mg capsule sig: two (2) capsule po qid (4 times a day) as needed for diarrhea. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 14. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 15. gentamicin 40 mg/ml solution sig: three y (320) mg injection q24h (every 24 hours) for 7 doses. disp:*7 doses* refills:*0* 16. zofran 8 mg tablet sig: one (1) tablet po every 4-6 hours as needed for nausea. disp:*1 month's supply* refills:*0* 17. outpatient lab work please have a chem 10 checked on , , and and have the results sent to dr.. 18. iv fluids please provide patient with 1l ns with 50 meq of potassium, iv, to be given 5x/week. please give two week's supply with no refills. 19. iv fluids please provide patient with 1l ns, iv, to be given 2x/week. please give two week's supply with no refills. discharge disposition: home with service facility: critical care systems discharge diagnosis: sepsis pseudomonal bacteremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with low pressure and were found to have bacteria in your , likely from your line. your tunneled line was removed and you had a picc line placed. your symptoms improved. you will need to continue to take iv antibiotics through . please weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. followup instructions: department: when: wednesday at 10:00 am with: , md building: (, ma) campus: off campus best parking: on street parking department: gastroenterology when: tuesday at 9:00 am with: , md building: lm bldg () campus: west best parking: garage department: gerontology when: thursday at 1 pm with: , m.d. building: lm campus: west best parking: garage procedure: central venous catheter placement with guidance diagnoses: other primary cardiomyopathies acidosis other chronic pain esophageal reflux toxic encephalopathy long-term (current) use of steroids severe sepsis unspecified acquired hypothyroidism depressive disorder, not elsewhere classified hypopotassemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure other specified cardiac dysrhythmias septic shock other acute pain other and unspecified infection due to central venous catheter other and unspecified coagulation defects septicemia due to pseudomonas posttraumatic stress disorder unspecified disorder of autonomic nervous system infective otitis externa, unspecified bacterial enteritis, unspecified 

Answer: The patient is high likely exposed to