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: darvocet-n 100 attending: chief complaint: increased secretions and work of breathing major surgical or invasive procedure: none history of present illness: 76 y/o m with pmh progressive ms s/p trach and g-tube placement for recurrent aspirations, recent esbl e. coli pna transferred from an osh with hypoxia and hypotension. the patient presented to on the day prior to admission after his trach tube had fallen out. his trach was replaced in the ed, and he was subsequently discharged. he returned to the with increased work of breathing, increased secretions from his trach, hypoxia (74% unclear o2 delivery), and bp 69/59. per report, his trach was suctioned aggressively. a l femoral central line was placed, and after 4l ivf his bp improved to 110/65 and hr improved to 100. at the time of transfer, he was satting 98% on 12l humidified air via trach mask. cxr demonstrated r-sided infiltrate/pneumonitis and his ua was positive. initial troponin was 0.2 and lactate 9.3. he was given vancomycin, ceftazadime (h/o pseudomonas sensitive) and gentamycin. history of e. coli in urine () resistent to bactrim and flouroquinolones. patient admitted in with hypoxic respiratory failure and rll aspiration pna. due to deterioration of ms in the acute setting as well as difficulty extubation recurrent aspiration, peg and trach were placed. sputum culture grew enterobacter resistent to ceftriaxone and ceftazidime. treated initially with vanc/zosyn, then narrowed to po cipro. in , admitted to osh with lll pna, esbl e. coli and treated with ertapenem. in the ed inital vitals were, 98 116 90/60 20 100% 15l. lactate 3.1. he was given 1l ns, then transferred to the icu. on arrival to the icu, vs: 96.2; 126; 110/84; 22; 95% trach mask 15l; 40%. patient has diminished mental status though unclear whether this is close to his baseline. patient is unable to describe any further symtpoms, including chest pain and shortness of breath. review of systems: (+) per hpi, son added chronic b/l le weakness and right facial droop (-) per son, hcp, denies fever, chills, cough, chest pain. past medical history: - multiple sclerosis with elements (followed by dr. at ) - anemia , h/o guaiac + stools, but no colonoscopy or known source of gib - coronary artery disease status post multiple pci. - cath showed progression of diffuse disease: mid lad: 40 %, 1st diagonal: focal 80 %, 2nd diagonal: 95% proximal, proximal circumflex: focal 100 % in distal third, 2nd marginal: focal 70 % in proximal third, ramus: occluded at site of prior stenting, mid rca: long and irregular 30 % stenosis, pda: irregular 80 % mid-vessel stenosis, overall no intervention - heart failure with ef 40-45% - hyperlipidemia. - hypertension. - chemosis with left eyelid swelling, followed at meei. - osteoarthritis, right knee. - s/p total knee replacement r - history of uti. - neurogenic bladder social history: unable to obtain family history: unable to obtain physical exam: admission exam: vs: 96.2; 126; 110/84; 22; 95% trach mask 15l; 40%. general: alert, awake, follows command, can nod yes to questions heent: sclera anicteric, dry mm neck: supple, jvp not elevated lungs: trach in place, tachypneic, rhonchorous transmitted upper airway sounds throughout cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: peg tube in place, soft, non-tender, non-distended, bowel sounds present gu: foley in place, draining clear urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: wbc-5.9 rbc-3.09* hgb-9.5* hct-29.1* mcv-94 mch-30.7 mchc-32.6 rdw-13.9 plt ct-242 neuts-30* bands-51* lymphs-15* monos-0 eos-0 baso-0 atyps-0 metas-4* myelos-0 glucose-94 urean-43* creat-1.1 na-146* k-4.2 cl-114* hco3-23 angap-13 alt-17 ast-22 ld(ldh)-162 ck(cpk)-115 alkphos-40 totbili-0.3 ck-mb-4 ctropnt-0.03* albumin-2.5* calcium-7.7* phos-2.9 mg-1.8 lactate-3.7* . imaging: cxr - large scale consolidation in the right lower lung, predominantly lower lobe, was new earlier today compared to . it has grown slightly more radiodense over the past eight hours, probably active pneumonia. small right pleural effusion is presumed and should be monitored in order to detect any development of empyema. left lung is clear. cardiomediastinal silhouette is normal. the patient has a tracheostomy tube in standard placement. no pneumothorax. . cxr (following picc placement)- right pic line has been repositioned, tip is approximately 2 cm below the estimated location of the superior cavoatrial junction. extensive consolidation right mid and lower lung zone stable since , increased at the left base since consistent with worsening pneumonia. there is no pulmonary edema. heart size is normal. tracheostomy tube in standard placement. . microbiology: . **final report ** urine culture (final ): identification and sensitivity testing requested by dr #. enterococcus sp.. ~3000/ml. escherichia coli. ~1000/ml. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | escherichia coli | | ampicillin------------ =>32 r =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- =>64 r ceftriaxone----------- 8 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s linezolid------------- 2 s meropenem------------- <=0.25 s nitrofurantoin-------- 128 r <=16 s tetracycline---------- =>16 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s vancomycin------------ =>32 r . **final report ** . gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions.. bacterial culture results are invalid. please submit another specimen. . respiratory culture (final ): moderate growth commensal respiratory flora. work up all pathogens per dr. . escherichia coli. sparse growth. piperacillin/tazobactam sensitivity testing available on request. beta streptococci, not group a. sparse growth. pseudomonas aeruginosa. rare growth. piperacillin/tazobactam sensitivity testing performed by . . sensitivities: mic expressed in mcg/ml . _________________________________________________________ escherichia coli | pseudomonas aeruginosa | | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- =>64 r cefepime-------------- <=1 s 8 s ceftazidime----------- 16 r 16 i ceftriaxone----------- 2 i ciprofloxacin--------- =>4 r 1 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s 0.5 s piperacillin/tazo----- s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r brief hospital course: hospital course 76 y/o m with pmh progressive multiple sclerosis s/p trach and g-tube placement for recurrent aspiration pna, recent enterobacter and transferred from an osh with hypoxia, hypotension and focal consolidation on cxr. he was treated for a pneumonia with iv antibiotics and transferred to an ltac for further care. his hospital course was complicated by tachycardia and volume overload. . active issues # septic shock: at outside hospital, patient met sirs criteria with tachycardia, bandemia and tachypnea. he was afebrile, but hypotensive and not responsive to fluid boluses, and had a lactate of >9. cxr at outside hospital, and confirmed at showed new right lower lobe opacity. in addition, he had a positive urinalysis. patient was started on broad spectrum antibiotics with vancomycin, levofloxacin and meropenem to cover hospital acquired pneumonia and urinary tract infection, with history of esbl e.coli utis. lactate trended down, was 3 on arrival to , and was normal by hd1. patient required a total of 6l ns in fluids, and then was placed on phenylephrine for blood pressure support. pressors were weaned on hd1. patient had a picc line placed on hd1 for antibiotic administration, with plan to continue broad spectrum antibiotics for 14 days, day 1= . at the time of discharge, urine culture was positive for both enterococcus and ecoli, which were speciated to vre however < 3000 colonies so therfore not treated. sputum cultures were contaminated but speciated to pseudomonas and ecoli. blood cultures were still pending or negative at the time of transfer. at the time of transfer he was day of meropenem for esbl pneumonia. he completed 7 days of vancomycin which was discontinued prior to transfer given absence of culture driven data. - continue iv meropenem for 6 additional days to complete 14 day course . # hypoxic respiratory distress: thought to be due to recurrent pneumonia, likely aspiration despite tube feeds through peg. on arrival to icu, sat's were in the 90s on tach mask at fio2 35%. abg 7.44/34/87. patient was treated with broad spectrum antibiotics as above, with plan to treat for 14 days. patient was at his baseline at the time of discharge. interventional pulmonology saw patient while in-house and were concerned about recurrent aspirations and recommended that g-tube be changed to j-tube. head of bed was elevated to prevent aspirations in addition to frequent suctioning of oral secretions. he was diuresed prior to transfer given total fluid balance during his hospital stay was over 10 liters. he was placed on a lasix drip prior to transfer in an effort to achieve relative . - should be continued on bolus lasix 20 iv for net negative 1 liter per day. - at the time of discharge he was 7 liters up total length of stay. . # tachycardia: documented initially as sinus, with rates in the 120s. he went into atrial fibrillation with short bursts into the 190s that were felt to be supraventricular. as blood pressure was stable, home metoprolol was restarted on the evening of admission and was titrated up for improved heart rate control. tachycardia coincided with aggressive diuresis. he flipped back into sinus rhythm and his metoprolol was ultimately down-titrated to tid dosing. - increase metoprolol to 12.5 mg tid . chronic issues: # cad s/p stent- unknown when stents were placed, but at higher risk of cardiac event in the setting of sepsis, hypoperfusion, and tachycardia. aspirin and were continued. cardiac enzymes were flat. . # anemia- patient with chronic anemia and history of guaiac positive stools. no signs of bleeding from recent egd prior to peg placement in 08/. no colonoscopy records. baseline hct 26-29. was 29 on arrival. noted to have coffee grounds in oral suction. he was started on iv protonix for week course. - start iv protonix for week course. . # htn - continued home metoprolol as above. . # schf - ef in 40-45% with focal wma. . # dm - started on humalog insulin sliding scale while an inpatient. . # ms - history of progressive ms, also recently developed symptoms and started on carbidopa-levodopa. continued all home medications includeing baclofen and sinement. . # transitional issues: - blood cultures pending - code status: full (discussed at length with patient and health care proxy while hospitalized. patient was able to express understanding regarding discussion and wish for continued full code status) medications on admission: #. heparin (porcine) 5,000 unit/ml one (1) injection tid #. carbidopa-levodopa 25-100 mg, 1 tab tid #. bisacodyl 5 mg two (2) tablet po daily (daily) prn constipation #. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid #. senna 8.6 mg tablet one (1) tablet po bid prn constipation. #. albuterol sulfate 2.5 mg /3 ml (0.083 %) one (1) inhalation q6h #. ipratropium bromide 0.02 % solution one (1) inhalation q6h #. aspirin 81 mg one (1) tablet, chewable po daily (daily). #. baclofen 10 mg one (1) tablet po tid (3 times a day). #. citalopram 20 mg tablet sig: one (1) tablet po daily #. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). #. metoprolol tartrate 25 mg 0.5 tablet po bid (2 times a day). #. clopidogrel 75 mg tablet sig: one (1) tablet po daily discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. baclofen 10 mg tablet sig: one (1) tablet po tid (3 times a day). 4. citalopram 20 mg tablet sig: one (1) tablet po once a day. 5. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 10. mucinex 600 mg tablet extended release sig: one (1) tablet extended release po twice a day. 11. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 12. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po tid (3 times a day). 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. 14. bisacodyl 10 mg suppository sig: one (1) rectal once a day as needed for constipation. 15. milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml po at bedtime as needed for constipation. 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 17. heparin, porcine (pf) 10 unit/ml syringe sig: five (5) ml intravenous prn (as needed) as needed for line flush. 18. meropenem 500 mg recon soln sig: one (1) injection intravenous every six (6) hours for 6 days. 19. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 20. furosemide 10 mg/ml solution sig: ml injection twice a day as needed for volume overload: titrated as directed by supervising md urine output . discharge disposition: extended care facility: for the aged - macu discharge diagnosis: 1. pneumonia, paroxysmal atrial fibrillation 2. multiple sclerosis status post tracheostomy discharge condition: mental status: clear and coherent. level of consciousness: alert activity status: bedbound. discharge instructions: you were admitted for increased oxygen requirement, low blood pressure and increased respiratory secretions that were secondary to a pneumonia. you were treated with strong antibiotics initially to cover for urinary and respiratory sources. ultimately, bacteria was isolated from your respiratory secretions and you will require a total of fourteen days of antibiotic therapy. your hospitalization was complicated by a fast heart rate which was treated with increased doses of your metoprolol. you also developed volume overload, which was treated with a diuretic, furosemide. lastly you were noted to have blood in your stomach so you were started on 6 weeks of anti-acid medication. the following changes were made to your medication list: 1. continue lasix (furosmide): 10mg-20mg iv for urine out put 1 liter per day for several days 2. continue meropenem 500 mg iv every 6 hours for 6 more days 3. increase metoprolol to 12.5mg three times a day 4. start pantoprazole 40mg iv twice a day for four additional weeks followup instructions: please follow-up with the providers at your long term acute care facility. md procedure: venous catheterization, not elsewhere classified diagnoses: anemia, unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled other pulmonary insufficiency, not elsewhere classified unspecified septicemia atrial fibrillation percutaneous transluminal coronary angioplasty status sepsis other and unspecified hyperlipidemia pneumonitis due to inhalation of food or vomitus chronic systolic heart failure multiple sclerosis gastrostomy status osteoarthrosis, unspecified whether generalized or localized, lower leg tracheostomy status paroxysmal supraventricular tachycardia neurogenic bladder nos 

Answer: The patient is high likely exposed to