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: nitrofurantoin / yellow dye / iron / calcium attending: chief complaint: increased abdominal pain major surgical or invasive procedure: ercp history of present illness: 67 yo f with h/o pud which was c/b gastric outlet obstruction s/p vagotomy, antrectomy and bilroth ii repair c/b jejunal stump leak and recurrent liver abscesses s/p drainage and fistula creation, polymicrobial bsi s/p treatment course of daptomycin, meropenem, fluconazole (finished course of iv abx on ) presenting with worsening abdominal pain. patient has had an extensive medical course since surgery in including multiple hospitalizations and rehab stays and was on iv abx until . she was living in an ecf () until around when abx were discontinued and went home to live with her husband. she was doing okay at home, with increasing po intake and a stable level of pain and nausea however over the last few days, her pain has worsened. per family, on tuesday last week patient was admitted to hospital after a fall. patient doesn't remember the fall, but she had just taken several pain medications (incl dilaudid, which she takes every 4 hours 4 mg without fail) and per her daughter and husband she often gets confused after taking her medications. she had a workup at hospital which showed no fractures or other process, and was discharged within a few hours to ecf again. . over the last few days at , paitent has complained of worsening pain and stable nausea. denies any vomiting, constipation, cough, fevers, chills, or other symptoms. she presented today for worsening pain despite her pain medications. pain is stabbing in nature associated with nausea. also thinks that her fistual output may be increasing. . in the ed, initial vs were 98.8 100 111/60 24 94% ra. ed exam with diffuse ttp mainly over the ruq/rlq. ostomy site with green cloudy fluid. labs notable for wbc 26.1, hct 27.7 (at baseline), alt 131, ast 51, na 132, hco3 19, alk phos 1452. ct abd/pelvis with left lower lobe opacification compatible with pneumonia, decreased mid abdominal collection. she received dilaudid 1 mg iv x 2, zofran as well as iv ativan. surgery consulted in ed, recommended ct abd with contrast, ct abd was done which showed abscesses largely unchanged but lll pna. surgery recommended no intervention now, admit to medicine for iv abx for pna with surgery following. pt was given dose of vanco/zosyn for hcap. . currently, patient complains of pain, much imprved from when she came in, howver she is not oriented to place or year having just received iv ativan and dilaudid. per daughter who gave most history, patient veyr often gets like this after receiving pain or anxiety medications. . per opt id note: subsequent course after initial surgery was complicated by polymicrobial bsi (enterobacter cloacae, vre, mrsa, clostridium) and hepatic abscess requiring drainage on (enterobacter, enterococcus) s/p drain removal and prolonged course of antibiotic therapy (daptomycin, ertapenem) ending . . she was re-admitted on with a recurrent fluid collection. treatment with daptomycin and meropenem was re-initiated. she underwent ct guided drainage of that major collection and cultures grew albicans and , vre. micafungin was added to her antibiotic regimen. . in the setting of a persistent leukocytosis, she was found to have a new liver abscess on and underwent ct guided drainage with fluid growing vre, mrsa and yeast. on , her antibiotics were simplifed to tigecycline, micafungin. however due to abdominal cramping which may have been in part related to tigecycline, her regimen was changed to daptomycin, ertapenem, and fluconazole on . . on she was readmitted to the hospital for elevation of lfts and increasing abdominal pain. ct of the abdomen on showed an increased fluid collection in the caudate lobe of the liver measuring 2.1x2.3cm. patient had ct guided drainage of the fluid collection on and culture results grew klebsiella pneumoniae that was pansensitive. patient was maintained on daptomycin and fluconazole however ertapenem was changed to meropenem on . decision was made to maintain the patient on meropenem on discharge instead of ertapenem for coverage of enterbacter which grew previously as she seemed to have improvement in her abdominal pain, transaminitis, and remained afebrile with meropenem. dosing was changed from q6h to q8h to help ease administration of the medicine. . antibiotic course: daptomycin, ertapenem daptomycin linezolid meropenem tigecycline (switched due to abd cramping) micafungin abx changed to daptomycin, ertapenem, and fluconazole on discharge daptomycin and fluconazole continued from previous discharge and ertapenem changed to meropenem . she had a ct of the abdomen on which showed some minimal improvement in previously seen fluid collections near the liver though a new 2cm fluid collection was found in between the loops of the jejunum (not amenable to percutaneous drainage). on , she was taken off daptomycin, meropenem. an was started on bactrim ds 1 tab po bid and continue fluconazole 400mg po daily. past medical history: chronic back pain sciatica htn pud adrenal adenoma uterine ca s/p hysterectomy depression anemia of chronic disease recurrent hepatic abscess polymicrobial bacteremia - enterobacter cloacae, vre, mrsa, clostridium - s/p several month course of abx, most recently daptomycin and meropenem (see id opat note for details) abdominal fluid collections growing albicans and , vre right hepatic vein thrombosis, on warfarin . psh: eus, pyloric ulcer bx, perigastric lnb () egd with duodenal stricture dilation () vagotomy and antrectomy with b2 reconstruction () re-exploration,lateral duo tube and feeding j-tube () ct-guided catheter drainage of liver abscess () perforated cyst/appendix s/p sbr, appendectomy cystectomy as a teenager s/p hysterectomy for uterine cancer @age 29 social history: lives at home with husband, was in long term rehab ( ecf) since her discharge in . former , half pack per day. denies alcohol use. family history: father with peptic ulcer disease physical exam: on admission: vs - 97.0 119/66 89 20 95% 2l general - thin and frail appearing f in nad, comfortable, appears sleepy heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - + crackles about 1/3 up from base of l lung field, no wheezes, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft, diffusely ttp more prominantly in rlq, no rebound/guarding, fistula output on r side with green turbid fluid, no masses or hsm extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, alert, oriented ot self, month, not to year or place (knows she is at hospital but thinks ), cns ii-xii grossly intact, muscle strength 5/5 throughout on discharge: vs: gen: cv: pulm: abd: extr: neuro: pertinent results: 10:15am blood wbc-20.1* rbc-3.14* hgb-8.3* hct-26.5* mcv-84 mch-26.6* mchc-31.5 rdw-19.7* plt ct-612* 06:10am blood glucose-83 urean-21* creat-0.5 na-135 k-4.6 cl-104 hco3-21* angap-15 06:10am blood calcium-8.3* phos-4.4 mg-2.1 06:10am blood pt-16.3* ptt-26.6 inr(pt)-1.4* 05:17am blood wbc-19.2* rbc-2.83* hgb-7.5* hct-24.0* mcv-85 mch-26.6* mchc-31.3 rdw-20.6* plt ct-457* 06:10am blood glucose-83 urean-21* creat-0.5 na-135 k-4.6 cl-104 hco3-21* angap-15 06:10am blood calcium-8.3* phos-4.4 mg-2.1 4:45 am urine source: catheter. **final report ** urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r 12:29 am stool consistency: soft **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 5:42 pm blood culture 2 of 2. **final report ** blood culture, routine (final ): no growth. 9:52 am urine source: catheter. **final report ** urine culture (final ): no growth. ct abd: impression: 1. left lower lobe consolidation concerning for pneumonia. in addition, stable areas of right nodular opacification since . 2. interval decrease in mid abdominal collections in the region of prior surgery at the duodenal stump with no new fluid collections identified; however, a few small bubbles of gas remain with the shrunken residual collection. 3. stable appearance of enterocutaneous fistula within the right mid abdominal wall. 4. stable appearance of intrahepatic biliary dilation. correlation with laboratory data and other clinical factors is recommended; sequelae of a stricture or even potentially a stone is possible despite the lack of change. a small calcified gallstone on the prior study is now absent and may have passed in the interim. 5. stable appearance of markedly narrowed main portal vein and attenuation of the left portal vein which is probably occluded with collateral flow. persistent areas of differential enhancement of the liver may accordingly be related to different flow patterns although it is difficult to exclude cholangitis. liver & gallbladder us: impression: 1. turbulent flow in the proximal portion of the main portal vein consistent with severe narrowing as seen on the preceding ct. 2. the left portal vein could not be visualized, which could be related to thrombosis, as seen on the ct. 3. intrahepatic biliary dilatation consistent with postinflammatory stricture as noted previously. gall bladder wall thickening appears to relate to this contiguous scarring/inflammatory change. cxr: impression: improved, but still present left lower lobe infiltrate. ct abd: impression: 1. status post billroth 2 with partial small bowel obstruction of the efferent limb of the gastrojejunostomy, with marked upstream dilatation of the jejunal limb continguous with the duodenal stump, and moderate gastric distention. 2. increase in extraluminal gas in right upper quadrant including along the border of the left lobe of the liver, near the oversewn duodenal stump and proximal jejunum, and at the base of the enterocutaneous fistula. compared to , there is a new 2.9 x 1.3 cm rim enhancing aortocaval fluid collection near liver hilum. 3. stable intrahepatic biliary dilatation and left chronic portal vein occlusion with cavernous transformation. 5. persistent bibsilar pneumonia, improved on the left but worsened on the right. ecg: sinus rhythm with an atrial premature beat. baseline artifact. since the previous tracing ventricular premature beat is not seen. atrial premature beat is new. brief hospital course: 67 yo f with h/o pud which was c/b gastric outlet obstruction s/p vagotomy, antrectomy and billroth ii repair c/b jejunal stump leak and recurrent liver abscesses s/p drainage and fistula creation, polymicrobial bsi s/p treatment course of daptomycin, meropenem, fluconazole (finished course of iv abx on ) presenting with acute onset sharp abdominal pain, lll infiltrate on cxr and ct and unchanged abdominal collections . # transaminitis: this is likely related to hepatic abscesses which appear stable on ct scan vs hepatic vein thrombosis, although is on coumadin. us and ct abdomen largely unchanged from prior. she was placed on linezolid and meropenem. she underwent ercp on 10/27th and was hold off coumadin prior to her going over for ercp. after she returned, heparin gtt was started with bridge to warfarin. inr goal is . she became supratherapeutic and her coumadin was held until her inr normalized. lfts improved prior discharge. inr was 1.7. the patient was send home with to continue inr monitoring. . # lll pneumonia/leukocytosis: most likely related to pna despite lack of symptoms from pna or cough. patient does have leukocytosis however to 26, with elevated alk phos and transaminitis. imaging does not support intra-abdominal process, but given extensive history, still a concern. the patient has uti with enterococcus sp., blood cultures x 2 and stool were negative. knowing her history with multiple drug resistant organisms in blood stream infections, including vre, enterobacter resistant to pip/tazo (from ), she was changed to iv linezolid/meropenem. id was consulted and their recommendations were followed. the patient underwent empirical treatment with iv linezolid, meropenem and fluconazole, after completion of the course, she was restarted on her home antibiotic coverage with bactrim ds and po fluconazole. repeat urine cultures were negative. she will continue to follow up with id as outpatient. on discharge, patient still has mild leukocytosis, was afebrile with stable vital signs. . #sbo: abdominal pain: worse in the last few days, abdominal pain can be associated with pna. ct abd doesn't appear to be changed from prior, nausea is stable, no diarrhea or vomiting. repeat ct scan on demonstrated partial bowel obstruction. the patient was made npo with ngt, ivf and nutritional service was called for tpn recommendations. picc line was placed and tpn was started on . on , ngt was removed, and diet was advanced on , which were well tolerated. diet was advanced to regular on , and tpn was discontinued. patient tolerated regular diet well with good appetite and adequate oral intake. . #anemia of chronic disease: the patient has a history of anemia with hct ~ 25. on hct was 22.1 and patient received one unit of rbc. after transfusion, hct improved to baseline and was 24.0 prior discharge. patient's pcp will continue to monitor her hct as outpatient. . #chronic pain: the patient has a history of chronic pain and takes soma, dilaudid and hyoscyamine. fentanyl patch was added to achieve better pain control per chronic pain service. the patient was discharged home with instruction to taper down her fentanyl patch within 3 weeks. instructed to monitor patient's pain and will contact surgery service at with any questions or concerns. . at the time of discharge on , the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. the patient was discharged home with services and home pt. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: -carisoprodol 350 mg tablet by mouth three times daily -citalopram 10 mg tablet by mouth daily -dronabinol 2.5 mg capsule by mouth twice daily -hydromorphone 2 mg tablet 2 tablet(s) by mouth every 4 hours -hyoscyamine sulfate 0.375 mg tablet daily -megestrol 40mg -metoprolol tartrate 50 mg tablet - 1 tablet(s) by mouth twice a day -mirtazapine 15 mg tablet by mouth at bedtime -pantoprazole 40 mg tablet by mouth daily -sulfamethoxazole-trimethoprim - 800 mg-160 mg tablet - -warfarin 0.5 daily -flagyl 200mg 2tabs daily -fentanyl 25mcg/hr tp q72h -docusate sodium 100 mg capsule - 1 capsule(s) by mouth twice daily -polyethylene glycol 3350 -17 g daily discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). disp:*60 tablet(s)* refills:*0* 2. carisoprodol 350 mg tablet sig: one (1) tablet po tid (3 times a day). 3. hydromorphone 2 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. disp:*60 tablet(s)* refills:*0* 4. hyoscyamine sulfate 0.375 mg capsule,extended release 12 hr sig: one (1) capsule,extended release 12 hr po bid (2 times a day). disp:*60 capsule,extended release 12 hr(s)* refills:*0* 5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. megestrol 400 mg/10 ml (40 mg/ml) suspension sig: one (1) po bid (2 times a day). disp:*60 * refills:*2* 10. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 11. citalopram 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 12. bactrim ds 800-160 mg tablet sig: one (1) tablet po twice a day: start on . disp:*60 tablet(s)* refills:*0* 13. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 14. warfarin 1 mg tablet sig: one (1) tablet po once a day: please continue to check inr. therapeutic inr . disp:*30 tablet(s)* refills:*2* 15. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch transdermal every seventy-two (72) hours for 3 doses. disp:*3 patches* refills:*0* 16. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch transdermal every seventy-two (72) hours for 3 doses: please use 50 mcg/hr patch x 3 times, then continue with 25 mcg/hr patch x 3, then stop fentanyl patch. disp:*3 patch* refills:*0* 17. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: northeast clinical services discharge diagnosis: 1. left lower lobe pneumonia 2. partial small bowel obstruction 3. left portal vein thrombosis 4. chronic pain 5. urinary tract infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. . right abdominal drain (ostomy) site: empty pouch when it is full and document output from drain site. change ostomy appliance twice a week. monitor erythema and induration peri drain site. . please call your doctor or nurse practitioner if you experience the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain is not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. . coumadin (warfarin): what is this medicine used for? this medicine is used to thin the blood so that clots will not form. how does it work? warfarin changes the body's clotting system. it thins the blood to prevent clots from forming. what you should contact your healthcare provider : signs of a life-threatening reaction. these include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. call your doctor if you are unable to eat for several days, for whatever reason. also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. these problems could affect your coumadin??????/warfarin dosage. coumadin (warfarin) and diet: certain foods and beverages can impair the effect of warfarin. for this reason, it's important to pay attention to what you eat while taking this medication. until recently, doctors advised taking warfarin to avoid foods high in vitamin k. this is because large amounts of vitamin k can counteract the benefits of warfarin. however, recent research shows that rather than eliminating vitamin k from your diet, it is more important to be consistent in your dietary vitamin k intake. these foods contain vitamin k: fruits and vegetables, such as: kiwi, blueberries, broccoli, cabbage, sprouts, green onions, asparagus, cauliflower, peas, lettuce, spinach, turnip, collard, and mustard greens, parsley, kale, endive. meats, such as: beef liver, pork liver. other: mayonnaise, margarine, canola oil, soybean oil, vitamins, soybeans and cashews. limit alcohol. alcohol can affect your coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. serious problems can occur with alcohol and coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. binge drinking is not good for you. be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. monitoring: the doctor decides how much coumadin??????/warfarin you need by testing your blood. the test measures how fast your blood is clotting and lets the doctor know if your dosage should change. if your blood test is too high, you might be at risk for bleeding problems. if it is too low, you might be at risk for forming clots. your doctor has decided on a range on the blood test that is right for you (). the blood test used for monitoring is called an inr. use of other medications: when coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. other medicines can also change the way coumadin??????/warfarin works. it is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. the will check you blood for coumadin level. they will send results to your pcp (dr. ) and he will continue to adjust your coumadin intake. . please continue to taper down your fentanyl patch as prescribed. followup instructions: department: infectious disease when: thursday at 10:30 am with: , md building: lm bldg () campus: west best parking: garage . department: surgical specialties when: wednesday at 10:45 am with: , md building: (, ma) campus: off campus best parking: parking on site . please follow up with you pcp ( dr. ) to continue monitor you inr level in weeks after discharge. procedure: parenteral infusion of concentrated nutritional substances endoscopic retrograde cholangiopancreatography [ercp] injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified hyperpotassemia anemia of other chronic disease other chronic pain urinary tract infection, site not specified toxic encephalopathy unspecified essential hypertension unspecified septicemia hyposmolality and/or hyponatremia severe sepsis personal history of tobacco use other opiates and related narcotics causing adverse effects in therapeutic use personal history of malignant neoplasm of other parts of uterus dysthymic disorder septic shock abscess of liver other specified disorders of biliary tract personal history of venous thrombosis and embolism streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] drug-induced delirium delirium due to conditions classified elsewhere unspecified intestinal obstruction leukocytosis, unspecified acquired absence of both cervix and uterus fistula of intestine, excluding rectum and anus personal history of peptic ulcer disease portal vein thrombosis benzodiazepine-based tranquilizers causing adverse effects in therapeutic use status of other artificial opening of gastrointestinal tract personal history of methicillin resistant staphylococcus aureus essential thrombocythemia malnutrition of moderate degree body mass index less than 19, adult infection with microorganisms with resistance to multiple drugs alopecia, unspecified 

Answer: The patient is high likely exposed to