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: sulfa (sulfonamides) / ivp dye, iodine containing / morphine / famotidine / ranitidine attending: chief complaint: hypertensive emergency enteroperitoneal fistula's/anastamotic leaks major surgical or invasive procedure: pigtail catheter placement and removals picc line placement history of present illness: 68 yo speaking female with h/o htn, cad, pvd, chf (ef 25% and diastolic dysfunction), h/o breast cancer s/p tamoxifen and transferred from the sicu for uncontrolled htn and + troponin. pt has h/o colon cancer, s/p partial colectomy . post-op course c/b pna, and pulmonary edema. readmitted on with rectal bleeding, found to have an anastomotic leak/bowel perforation. underwent small bowel resection and gastrostomy tube placement on , now on tpn and npo. pod #11, noted to have another anastomotic leak, with drainage of feculent material. vac dressing placed. course c/b pna, respiratory failure, ards requiring intubation, then tracheostomy. a peritoneal swab grew vre, as well as albicans. started on linezolid and fluconazole (days #24 & 40, respectively). patient d/c'd to rehab on . readmitted to sicu on with diffuse body pain and chest pain without radiation/sob/n/v. found to have bp=182/105, hr=95. in ed, ekg showed q's v1-v3, minimal st elv v2-v3 stdep v4-v6 but not much different from baseline. trop 1.02, peak at 2.0, flat ck at 20. cardiology consulted, not good cath candidate as suspect multivessel disease, and patient not candidate for cabg. admitted to micu, started on zosyn (#3) with resolution of fevers, esmolol gtt --> labetalol gtt --> iv antihypertensives. also with change in mental status changes with negative head ct that are now improved. past medical history: 1. chf with ef 25% 2. hypertension 3. breast cancer dx 7 years prior to admission treated with chemotherapy, lumpectomy and radiation 4. colon adenocarcinoma s/p right colectomy and numerous complications as per above hpi 5. vaginal bleeding associated with tamoxifen treatment and fibroids--followed by ob/gyn as outpt. social history: only speaking woman with two grown children family history: deferred physical exam: 97.1 120's/80's 70's 16 95%ra gen: nad, non-toxic, cooperative, follows commands heent: facial flushing (constant), eomi, perrl, mmm, no op lesions neck: 8cm jvp, no lad heart: rrr, holosystolic murmur radiating to l axilla. no gallops. laterally displaced pmi. lungs: trace crackles bibasilarly. abd: rlq pigtail, g-tube, midline vac dressings c/d/i. + bowel sounds. tender to deep palpation over entire abdomen. ext: trace bipedal edema to mid-shins. warm extremities. 2+ dp/pt's. pertinent results: 05:10am blood wbc-8.3 rbc-3.18* hgb-9.1* hct-27.4* mcv-86 mch-28.6 mchc-33.2 rdw-17.9* plt ct-241 05:10am blood neuts-62.0 lymphs-28.7 monos-8.7 eos-0.5 baso-0.1 05:10am blood anisocy-1+ macrocy-1+ microcy-1+ 05:10am blood plt ct-241 05:10am blood pt-12.7 ptt-24.9 inr(pt)-1.0 05:10am blood glucose-112* urean-41* creat-0.7 na-137 k-3.2* cl-98 hco3-32* angap-10 03:13am blood alt-79* ast-30 ck(cpk)-20* alkphos-245* amylase-98 totbili-0.9 03:13am blood lipase-47 04:14am blood ck-mb-notdone ctropnt-1.54* 06:53pm blood ck-mb-notdone ctropnt-2.00* 12:25pm blood ctropnt-1.02* 05:10am blood calcium-9.4 phos-3.5 mg-2.0 05:00am blood calcium-8.4 phos-2.3* mg-1.9 iron-109 cholest-150 05:00am blood caltibc-192* ferritn-911* trf-148* 04:14am blood vitb12-777 folate-11.1 05:00am blood triglyc-166* hdl-24 chol/hd-6.3 ldlcalc-93 04:14am blood tsh-0.94 10:55pm blood lactate-2.1* 10:55pm blood freeca-1.23 echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the septum, anterior and inferior walls. the apex is also near akinetic, but not aneurysmal. no left ventricular thrombus is seen. no left ventricular aneurysm is seen. there is mild global right ventricular free wall hypokinesis. the ascending aorta is moderately dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with extensive regional systolic dysfunction most c/w multivessel cad. moderate-severe mitral regurgitation. moderate pulmonary artery systolic hypertension. mild aortic regurgitation. cta: there is no evidence of filling defect within the pulmonary arteries to suggest pulmonary embolism. moderate sized bilateral pleural effusions and compressive atelectasis are present. nonspecific patchy ground glass opacities are present bilaterally. the heart is enlarged. there is no pericardial effusion. soft tissue density measuring approximately 2 cm is seen within the right axilla. this may relate to a confluence of veins. the patient's central venous catheter is also noted in this location. there is no mediastinal or hilar lymphadenopathy. noncontrast images demonstrate calcification within the aorta and coronary arteries. additionally, within the right lobe of the thyroid gland, there is a low density lesion measuring 3.4 x 3.0 cm. this could be further evaluated with thyroid ultrasound if clinically indicated. an ng tube is present. abdomen with contrast: the liver, spleen, pancreas, gallbladder, right adrenal gland are within normal limits. the left adrenal gland and kidneys are unchanged in appearance compared to the prior exam. there is no retroperitoneal lymphadenopathy. a pigtail drainage catheter is noted in the right perihepatic region, within a small collection of heterogeneous density fluid containing several bubbles of gas. overall, this collection has decreased markedly in size since the prior study. lower on the right side of the abdomen is a second collection, around and adjacent to the second right-sided drain. this second collection contains oral contrast material, indicating a persistent connection with the bowel. this collection has also decreased markedly in size since the prior study. other fluid collections in the left upper abdomen have also decreased in size and do not appear to connect with the bowel. pelvis with contrast: a calcified fibroid uterus is again noted. the volume of fluid within the pelvis has diminished, such that no fluid is evident on today's exam. there is no inguinal or deep pelvic lymphadenopathy. soft tissue defects about the midline abdomen and several centimeters to the left of the midline defect is again noted. bone windows: multilevel degenerative changes are present within the spine. no suspicious lytic or sclerotic bony lesions are seen. multiplanar reformatted images of the chest do not demonstrate pulmonary embolism. multiplanar reformatted images of the abdomen and pelvis redemonstrate two right-sided fluid collections, overall markedly decreased in size in the interval. impression: 1. no evidence of pulmonary embolism. 2. right thyroid nodule measuring 3.4 cm in greatest dimension. if clinically indicated, this could be further assessed with ultrasound. 3. bilateral pleural effusions and atelectasis. 4. coronary artery calcifications. 5. overall, substantial interval decrease in the volume of two right-sided abdominal fluid collections, both of which contain high density material consistent with contrast on today's exam. no new collections evident. 6. interval decrease in size of left upper abdomen fluid collections, one of which has resolved. 7. bulky fibroid uterus. : ct abdomen w/iv contrast: the lungs again demonstrate bilateral pleural effusions with associated compressive atelectasis, unchanged compared to the recent prior study. the liver, gallbladder, spleen, adrenals, kidneys, pancreas, and ureters are unchanged compared to the recent prior study. there is again demonstrated a right perihepatic pigtail catheter with a small amount of adjacent perihepatic fluid. this collection appears slightly smaller than on the prior study. there has been interval removal of the previously seen pigtail catheter in the right inferior collection. there is a persistent oval shaped low attenuation collection in this location, measuring approximately 6.6 x 4.1 cm, slightly smaller than on the prior study. extraluminal gas is seen adjacent to the liver tip. there are no new fluid collections identified. ct pelvis w/iv contrast: the distal ureters, urinary bladder, rectum and sigmoid are unchanged in appearance. there is again demonstrated a calcified fibroid uterus. soft tissue defects about the midline of the abdomen are again demonstrated. bone windows: there are no suspicious lytic or sclerotic lesions. impression 1. unchanged effusions and associated compressive atelectasis. 2. slight decrease of right-sided perihepatic collection. 3. interval removal of right flank pigtail catheter with persistent slightly smaller low attenuation collections in the lower right abdomen. 4. bulky fibroid uterus. ct of the pelvis w/o contrast: in the right flank is a 5.7 x 5.1 cm fluid collection containing extraluminal gas. the alternatives, benefits and risks including infection, bleeding, and bowel injury were explained to the patient's daughter by the radiology fellow dr. . informed consent was obtained. the patient did not speak english. she was placed supine on the ct table and a preprocedure time out confirming patient's identity and procedure to be performed was done. with the patient in the supine position the right flank was prepped and draped in the usual sterile manner. with ct guidance, a 10 french pigtail catheter was inserted into the collection. approximately 100 cc of fecolith material was aspirated. the drainage catheter was secured to the skin. nursing was present and continuously monitoring patient's status. conscious sedation was not administered. the patient tolerated the procedure well without immediate complications. impression: status post placement of 10 french pigtail catheter into right flank fluid collection. 100 cc of fecolith material was aspirated and sent to microbiology for culture. clinical indication: abscess. technique: volumetric images were obtained of the abdomen and pelvis without iv contrast. comparison is made to exams from and and multiple prior examinations. reformats were created. ct abdomen without iv contrast: there are bilateral pleural effusions with bibasilar atelectasis. there are coronary artery calcifications. a pigtail catheter is seen along the right lateral aspect of the liver. on multiple prior examinations there was a fluid collection in this region and on the current study it has almost completely resolved. a tiny amount of fluid and air remains in this cavity and the volume is much decreased from and probably also decreased from the tiny collection present on . a second pigtail catheter is also seen within an abscess collection in the right lower quadrant. this collection contains a large air- fluid level and on prior studies was seen to contain oral contrast indicating there is active communication with the small bowel. on the current study, there is no enteric contrast within this collection. oral contrast is only seen within the distal colon and may have been administered on a prior study. there are multiple smaller air and fluid collections along the right lateral abdominal wall which span from the dominant abscess collection to the right lower margin of the liver. these are present on prior examinations and are not changed. ct pelvis without iv contrast: there is a fibroid uterus. vascular calcifications are unchanged. there is an anterior abdominal incision which is left to close by a secondary intention. gauze material and a vacuum device are seen in the wound. impression: 1. resolution with no reaccumulation of perihepatic collection. a pigtail drain is located in this location. 2. essentially stable appearance of the abscess collection in the right lower quadrant. on this exam there is no active extravasation of oral contrast. there is no evidence of bowel obstruction. micro: gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): yeast(s). wound culture (final ): klebsiella pneumoniae. moderate growth. trimethoprim/sulfa sensitivity available on request. 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 e. coli and klebsiella species. escherichia coli. moderate growth. trimethoprim/sulfa sensitivity available on request. 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 e. coli and klebsiella species. yeast, presumptively not c. albicans. isolated from broth media only. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae escherichia coli ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r 16 i cefazolin------------- =>64 r 32 r cefepime-------------- r r ceftazidime----------- =>64 r r ceftriaxone----------- r r cefuroxime------------ 32 r r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s <=1 s imipenem-------------- <=1 s <=1 s levofloxacin---------- =>8 r =>8 r meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- 8 s <=4 s tobramycin------------ =>16 r =>16 r anaerobic culture (final ): no anaerobes isolated. brief hospital course: 1. hypertensive emergency/nstemi: pt admitted with diffuse body pains and found to have bp=182/105, hr=95. in ed, ekg showed q's v1-v3, minimal st elv v2-v3 stdep v4-v6 but not much different from baseline. trop 1.02, peak at 2.0, flat ck at 20. pain subsided, but recurred and pt sent to micu (this time with no ekg changes or enzyme leak). cardiology consulted, not good cath candidate as suspect multivessel disease, and patient not candidate for cabg. echo revealed ef 25% with 3+ mr and numerous regional wall motion abnormalities: mid lv hypo and apical akinesis. ms. hypertension was controlled with labetolol drip, then esmolol drip, then iv lopressor (since she was not taking po's) and iv vasotec. pt also had mild heart failure with pulmonary and peripheral edema in the setting of this nstemi so iv lasix was used for hypertension/maintenance of euvolemia. she is now on a stable dose of lasix at 50mg iv bid. aspirin suppository was maintained. she will be discharged with a statin crushed through g tube. she also has a clonidine patch qweekly. please increase dose of other anti-hypertensives if the clonidine patch is stopped (rebound phneomenon). she will need formal coronary eval (i.e. cath) once her gi issues are resolved. 2. fevers: previous peritoneal swabs grew vre, e.coli and yeast (). pt continued to spike fevers to 101.2 while on linezolid and fluconazole (days #23 and 40, respectively). zosyn started then had ruq ct-guided fluid collection drainage with pigtail placement, then defervesced. linezolid is being continued for potential persistence of vre. blood cultures persistently negative. ruq fluid collection drainage grew klebsiella and e.coli with suscpetibilities as per above. sensitivities returned , which revealed that both pathogens have extended-spectrum beta lactamase enzymes-->suggesting possible future failure of zosyn. therefore, pt was switched from zosyn to imipenem on . she needs to be on these 3 abx (fluconazole, imipenem, linezolid) for 2 weeks after all abdominal fluid collections have been drained. pt had dirty urine with same 2 pathogens on . 3. abdominal fluid collections: pt with anastomotic leaks from her previous bowel surgeries and were being drained percutaneously. ms. was kept npo during most of her hosptialization. she had 2 pigtail catheters draining the right side (now with only one rlq catheter), g-tube drain and midline vac dressing draining fluid. her ruq fluid collection (initially 5 x 6 cm) is now fully drained and her ruq pigtail is pulled. she failed her swallow-evaluation, based on aspiration risk. she was transitioned from iv ace-i and bb to per g-tube . her peritoneal cavity output has been decreasing from ~700-800 cc/day to < 100cc per day--suggesting her anastamotic leak is closing. she has f/u with dr. . if she passes her swallow evaluation at rehab, she may have po clears with close monitoring of output, per dr.. 4. htn: maintained initially on iv meds (lasix, metoprolol, enaliprilat) and transdermal (nitro and clonidine). switched to toprol xl 75 and lisinopril 15 mg per g-tube. goal sbp 90-100 given her low ef at 25% with 3+mr. 5. delerium: pt noted to have altered mental status and decreased sensorium during her hospitalizaiton. noted that her mental status deteriorated when famotidine was added to her tpn regimen. when the h2-blocker was discontinued and a ppi added for its replacement, her mental status cleared back to baseline. currently she is clear and at baseline. 6. anemia: pt with anemia of chronic disease by iron studies. b12 and folate normal. tsh normal. her hematocrit was maintained >30 for her co-existing cad. her inflammatory impetus for this aocd is likely her peritoneal fluid collections (abscesses)--therefore, epo or aranesp would likely not be helpful. should her anemia continue once her fluid collections are completely drained, a different inflammatory condition should be searched for (i.e. thyroid or endometrial cancer). 7. thyroid nodule: non-palpable 3.4 x 3.0 cm nodule in the right lobe. needs work-up as an outpt. likely non-functioning adenoma given normal tsh. 8. vaginal bleeding: hx of vaginal bleeding as outpt. has fibroids and hx of tamoxifen (endometrial stimulant) for breast cancer. seen by , md as a consult who felt this problem could be worked up as an outpt once her current problems are resolved. 9. fen: pt was actively diuresed during this hospitalization. she went into heart failure with her nstemi and diuresed well. her electrolytes were aggressively repleted as she may have scar and a focus for ventricular ectopy (although no evidence on telemetry). she was kept on tpn during this hospitalization. 10. dm: pt was kept on regular insulin sliding scale and kept on diabetic diet. she will be d/c'd with 53 units of regular in her tpn. no evidence of dka or hypoglycemic episodes. full code medications on admission: enalaprilat 0.625 mg iv q6h linezolid 600 iv q12h hydralizine 10mg iv prn dilaudid 0.5 mg iv q3-4 prn fentanyl patch 25mic/72h fluconazole 200mg iv qd lopressor 20mg iv q6h miconazole powder insulin ss discharge medications: 1. aspirin 300 mg suppository sig: one (1) suppository rectal daily (daily). disp:*30 suppository(s)* refills:*2* 2. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. disp:*qs * refills:*0* 3. nitroglycerin 2 % ointment sig: one (1) inch transdermal q6h (every 6 hours). disp:*120 inch* refills:*2* 4. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day): while non-ambulating. disp:*90 ml* refills:*2* 5. clonidine hcl 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qtues (every tuesday): remove for sbp < 100. disp:*qs patch weekly(s)* refills:*2* 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day: hold for sbp < 100 dbp < 60 hr < 60. disp:*30 tablet sustained release 24hr(s)* refills:*2* 7. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day: hold for sbp < 100 dbp < 60 hr < 60. disp:*30 tablet sustained release 24hr(s)* refills:*2* 8. pantoprazole 40 mg iv q24h 9. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 10. hydralazine hcl 10 mg iv q2-3h:prn for sbp >180 11. fluconazole 200 mg iv q24h 12. linezolid 600 mg iv q12h 13. furosemide 50 mg iv bid 14. lisinopril 10 mg tablet sig: one (1) tablet po once a day: hold for sbp < 100 dbp < 50. disp:*30 tablet(s)* refills:*2* 15. lisinopril 5 mg tablet sig: one (1) tablet po once a day: hold for sbp < 100 dbp < 50. disp:*30 tablet(s)* refills:*2* 16. imipenem-cilastatin 500 mg recon soln sig: one (1) solun intravenous every six (6) hours. disp:*qs * refills:*2* discharge disposition: extended care discharge diagnosis: hypertensive emergency enteroperitoneal fistulas heart failure discharge condition: stable discharge instructions: if you have these symptoms, call your doctor or go to er: -fevers/chills -abdominal pain -increased output from abdominal drains -nausea/vomiting -chest pain/shortness of breath -weight gain -leg swelling -headache, visual changes, bloody urine rehab: please check weekly cbc's, lft's, chem 10's. check daily chemistries since on ace-i and lasix. transfuse for hct < 28 and use lasix 30mg iv with blood transfusion administration. daily weights. if pt gains more than 3#'s, given extra lasix dose of 50mg iv. please give pills through g-tube. pt currently npo, before advancing diet to clear liquids, please have swallow evaluation. if she passes swallow evaluation, she can have clear liquids only, until she sees dr. . followup instructions: 1. provider: , m.d. where: surgical specialties phone: date/time: 1:45 2. provider: . wants to see patient when she will be discharged from rehab. phone: . procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances percutaneous abdominal drainage endoscopic control of gastric or duodenal bleeding transfusion of packed cells injection or infusion of oxazolidinone class of antibiotics diagnoses: subendocardial infarction, initial episode of care other postoperative infection cellulitis and abscess of trunk congestive heart failure, unspecified unspecified essential hypertension iron deficiency anemia secondary to blood loss (chronic) personal history of malignant neoplasm of breast personal history of malignant neoplasm of large intestine chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction combined systolic and diastolic heart failure, unspecified persistent postoperative fistula 

Answer: The patient is high likely exposed to