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: cefepime attending: chief complaint: sepsis, respiratory failure, pneumonia major surgical or invasive procedure: intubation and mechanical ventilation electrical and chemical cardioversion placement of left subclavian central venous hd catheter placement of right ij venous catheter placement of right radial arterial line hemodialysis history of present illness: mr. is 37 year old man, with a history of dm, who presented to on after a syncopal episode. there was a question of a seizure in the field prior to arrival. per his family he had a upper respiratory illness (starting ) with sneezing, cough for 7-10 days with decreased po intake and general malasie prior to presentation. he was in shock on admission, was intubated and started on levophed and tamiflu, levaquin, and vancomycin. h1n1 was originally suspected, however flu swab has remained negative. he developed mssa in the blood cultures and his antibiotics were narrowed to naficillin. he remained on vasopressors until . his course was complicated by arf with cr of 1.9 worsening to 7.2 thought to be atn and requiring hd for hyperkalemia to 6. he had a hd line placed on . he also had intermittant a. fib treated with cardizem as well as a wide complex tachycardia. echo showed a preserved ef without evidence of vegitation. on transport on he was paralysized and given boluses of versed and fentanyl. hr remained tachycardic in the 140s. past medical history: dm - diet controlled htn social history: works as a chef. lives in with parents. no tobacco or illicts. heavy drinker. family history: dmii. father cad. mom ra, cva, dm. two brothers with cad. physical exam: on admission: vitals t 100.6 p 147 bp152/90 o2 sat. 92% on cmv general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, 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: admission labs: 11:09pm wbc-12.5* rbc-4.12* hgb-12.8* hct-37.9* mcv-92 mch-31.1 mchc-33.8 rdw-14.8 11:09pm neuts-82* bands-1 lymphs-10* monos-6 eos-1 basos-0 atyps-0 metas-0 myelos-0 11:09pm plt count-214 11:09pm glucose-147* urea n-39* creat-5.4* sodium-144 potassium-4.6 chloride-104 total co2-25 anion gap-20 11:09pm albumin-2.2* calcium-7.5* phosphate-6.0* magnesium-2.2 11:09pm alt(sgpt)-52* ast(sgot)-104* ld(ldh)-437* ck(cpk)-238* alk phos-260* tot bili-5.2* 11:09pm pt-14.4* ptt-42.1* inr(pt)-1.2* . discharge labs: glucose urean creat na k cl hco3 angap 84 13 0.8 140 3.9 104 24 16 wbc rbc hgb hct mcv mch mchc rdw plt ct 5.9 3.58* 10.8* 33.1* 92 30.0 32.5 15.3 236 . imaging: ecg study date of 10:53:18 pm sinus tachycardia. incomplete right bundle-branch block. non-specific st-t wave changes. the p-r interval is 160 milliseconds. intervals axes rate pr qrs qt/qtc p qrs t 147 160 106 296/448 0 101 -60 . ecg study date of 3:16:42 am supraventricular tachycardia most likely representing atrio-ventricular nodal reentrant tachycardia but cannot exclude orthodromic atrio-ventricular reciprocating tachycardia. intervals axes rate pr qrs qt/qtc p qrs t 170 0 84 298/490 0 82 -95 . ct head w/o contrast study date of impression: no acute intracranial process. evaluation for infection is limited on ct. sinus disease. fluid within the mastoid air cells bilaterally. . ct torso w/o contrast study date of impression: 1. evaluation limited due to lack of iv contrast and streak artifact from overlying arms. multifocal pneumonia as seen on recent chest x-ray. 2. fatty liver. otherwise, non-contrast appearance of the abdomen and pelvis is unremarkable except for small amount of free fluid. . echocardiography the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with borderline normal free wall function. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. . chest (portable ap) study date of findings: in comparison with study of , there is little overall change in the appearance of the cardiomediastinal silhouette with extensive right paratracheal thickening. extensive left lung consolidation has somewhat decreased since the previous study. also, the area of opacification in the right lung has improved. . mr head w/o contrast study date of impression: 1. extensive confluent t2 and flair hyperintensities throughout the centrum semiovale and peritrigonal regions without restricted diffusion. the findings most likely represent sequelae of a systemic metabolic/hypoxic insult with additional considerations to include infectious or hiv-related processes such as pml or viral encephalopathy. given the marked hypotension 3 weeks prior, the findings could represent evolving watershed infarcts with pseudonormalization of the adc map or even osmotic demyelination in the appropriate context. correlation with the patient's history and followup examination with gadolinium administration is recommended in further evaluation. 2. bilateral mastoid air cell effusions as well as maxillary and sphenoid sinus disease, which may in part be related to recent intubation. . mr head w/ contrast study date of impression: patchy foci of enhancement throughout the signal abnormality within the centrum semiovale with primary differential considerations again including metabolic/hypoxic processes. the findings could relate to subacute infarcts relating to prior watershed event or osmotic demyelination. correlation with csf sampling is recommended. . emg study date of clinical interpretation: complex abnormal study. there is electrophysiologic evidence for a mild sensorimotor neuropathy with demyelinating and axonal features. although this can be seen in diabetes, the emg reveals ongoing denervation and chronic reinnervation in the upper and lower extremities, suggesting a subacute process. the differential diagnosis includes critical illness polyneuropathy and axonal variant of syndrome. an incidental moderate median neuropathy at the left wrist is noted (as in carpal tunnel syndrome). . microbiology: 2:19 pm blood culture source: line-cvl. **final report ** blood culture, routine (final ): klebsiella pneumoniae. 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. final sensitivities. sensitivity testing performed by microscan. meropenem = sensitive ( <=1 mcg/ml ). cefepime = resistant ( >=16 mcg/ml ). unasyn (ampicillin/sulbactam) = resistant ( >=16 mcg/ml ). sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin------------ =>16 r ampicillin/sulbactam-- r cefazolin------------- =>16 r cefepime-------------- r ceftazidime----------- =>16 r ceftriaxone----------- =>32 r ciprofloxacin--------- =>2 r gentamicin------------ <=1 s meropenem------------- s piperacillin/tazo----- 32 i tobramycin------------ =>64 r trimethoprim/sulfa---- <=2 s anaerobic bottle gram stain (final ): reported by phone to @ 0340 on - cc6d. gram negative rod(s). aerobic bottle gram stain (final ): gram negative rod(s). ==== 2:30 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. klebsiella pneumoniae. moderate growth. identification and sensitivities performed on culture # 286-2926k . pseudomonas aeruginosa. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | amikacin-------------- 8 s cefepime-------------- 8 s ceftazidime----------- 4 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem------------- 1 s piperacillin/tazo----- =>128 r tobramycin------------ =>16 r brief hospital course: this is a 37 y/o male with transfered from an osh after presenting in septic shock with staph pneumonia / bacteremia with a course complicated by arf and tachycardia. he grew mssa in blood/sputum (at the osh), klebsiella in his blood and klebsiella and pseudomonas in sputum at . . # severe septic shock: the patient had known bacteremia, pneumonia and sinus disease by ct scan at admission to osh. these findings, in addition to elevated mixed venous o2sat of 84% and his mottled appearance suggested a septic etiology. cardiogenic shock was deemed unlikely, given the pt's robust bp despite tachycardia to the 170s, high mixed venous o2sat, and preserved lvef on echo. . # community acquired pneumonia: at presentation, the patient's blood pressure was stable, off pressors. culture data was positive for mssa in the sputum and blood early in osh course. ct scan showed a multi-focal pneumonia, with l > r infiltrates, but no sign of empyema. tte showed no vegetations. h1n1 was a consideration, and the pt was initially treated for flu with tamiflu; however, after negative influenza dfa x 2 at the osh and another negative dfa at , tamiflu was stopped. patient completed a 14 day course of meropenem (inititially nafcillin/meropenem/gentamicin narrowed to meropenem). . # ventilator-associated pneumonia: after intubation at the osh, his sputum cultures at bidcmc grew klebsiella pneumoniae and pseudomonas in the sputum, and klebsiella in the blood. per id consult, patient's antiobitic regimen was changed from nafcillin/meropenem/gent to: solely meropenem--with a course from (the last negative blood culture) to , for a total of 14 days. . # klebsiella bacteremia: patient was treated with a 14 day course of meropenam. . # coagulase-negative staphylococcus bacteremia: this was felt to be line-related. pt was treated with 7 day course of vancomycin. . # acute respiratory distress: the patient had bilateral infiltrates on cxr and ct chest and high oxygen requirement. he had a long course of intubation (18 days), extubated on following precedex treatment. at discharge, the patient was satting well on room air. . # acute renal failure from acute tubular necrosis: due to hyperkalemia in the setting of arf, the pt required hd, and renal consult service followed him closely. patient was oliguric, then had post-atn diuresis, and renal function improved considerably, at discharge his cr was back to baseline. however, the patient had persistent hypomagnesemia on discharge requiring daily supplementation, likely magnesium wasting from recovering arf/atn. he was discharged on magnesium po supplementation with instructions to f/u labs in rehab. . # mental depression: after extubation, pt was found to have mental slowing with word-finding difficulties and inattention. both improved steadily during the hospitalization. this is most likely a hypoxic process given the extent of ventilatory support needed. mri with and without contrast showed patchy foci of enhancement throughout the signal abnormality within the centrum semiovale with primary differential including metabolic/hypoxic processes, subacute infarcts relating to prior watershed event, or osmotic demyelination. neurology suggested that this may be a congenital defect given the symmetry on mri; he has no prior mris. lp showed no evidence of bacterial infection but was notable for elevated protein, mildly low glucose, and only 4 wbcs. this can be c/w but less likely aseptic meningitis, csf cultures pending at time of discharge. patient is scheduled for neurology f/u as outpt with dr. . . # critical illness myopathy: patient developed myopathy during his icu stay. this is most likely critical illness myopathy given greater proximal than distal muscle weakness, prolonged failure to wean from mechanical ventilation, and initially elevated ck. given elevated protein in csf and viral prodrome, gbs is a consideration but less likely. emg showed mild sensorimotor neuropathy with demyelinating and axonal features with differential diagnosis including critical illness polyneuropathy and axonal variant of syndrome. neurology felt his history was more consistent with icu myopathy. he was followed by physical therapy and by discharge, his proximal muscles were 4+/5 in strength. . # magnesium deficiency: pt was noted to be persistently hypomagnesiemia despite aggressive repletion. he had no other electrolyte abnormalities, inc. k, ca. urinary mg excretion was extremely high at 355 mg/24 hr, likely due to postatn tubular dysfunction. he was started on po repletion and his mg will needed to be followed at rehab. . # tachycardia/ afib: although the patient's tachycardia appeared sinus on arrival, during his course he had couple runs of tachycardia that appeared to be regular svt with aberrancy that were self-limited and well-tolerated. his osh ekg showed rbbb as recently as , and there were reports of atrial fibrillation requiring treatment with diltiazem. at one point, the patient went into regular svt with aberrancy during dialysis, which was treated w/ lopressor 10, dilt 20 iv and dilt po60 with conversion back to sinus after 1-2 hours. atrial irritation was believed due to an ij that was too deep, and was subsequently pulled back. during another hd session, he again had aberrant svt, thought to be due to intracellular shifts. finally, the patient had another episode, during which he underwent synchronized cardioversion and was chemically cardioverted with amiodarone and adenosine--after this episode, adenosine was kept at the bedside. ep was consulted, and 24 hour amiodarone was completed. the patient had persistent tachycardia and hypertension during his hospitalization, treated with diltiazem, metoprolol, amlodipine, and hydralazine. diltiazem and the clonidine patch were discontinued in the micu. lisinopril was initiated. when he was transferred to the medical floor, he was in nsr. the patient was eventually discharged on lisinopril, metoprolol and amlodipine (all new medications for him). . # hypertension: the patient was frequently hypertensive to the 170s and 200s sbp. this was treated with a clonidine patch due to concern of agitation/anxiety as trigger in addition to diltiazem, metoprolol, amlodipine, hydralazine. diltiazem and the clonidine patch were discontinued in the micu, and lisinopril was initiated. the patient was eventually discharged on lisinopril, metoprolol and amlodipine. . # rash on back, abdomen, thighs: appeared to be consistent with a drug rash, which could have been triggerred by vanc or cefepime, although statistically cefepime would be more likely. both drugs were discontinued on ; and the patient changed to meropenem. the rash improved clinically, became less erythematous, and was treated with clobetasol 0.05% for abdomen, and clotrimazole/hydro groin cream for rash. vancomycin was later added back on, without worsening of the patient's rash--further increasing our suspicion that cefepime was the culprit. this rash had resolved by discharge and the clotrimazole and hydrocortisone cream were not continued. . # sacral decubitus ulcer, stage 2: this was cared for by nursning. . # dm2: patient was diet controlled prior to admission. he was treated with glargine 50 units qhs and iss. his insulin requirements improved as he clinically improved. would suggest discharging patient on glargine and insulin sliding scale. he will need teaching related to using insulin and using a sliding scale. please make sure he has close follow up with his pcp. # demand ischemia: during this hospitalization the patient presented with elevated troponin and ck, but ckmb was normal (2). this elevation was thought to be due to demand ischemia in the setting of shock and persistent tachycardia, as well as renal insufficiency. cardiac enzymes were trended, and his troponin did not continue to rise. . # mild lft elevation: this was thought to be prolonged hypotension. his lfts normalized over the course of his hospitalization. . # code: full code confirmed medications on admission: home: none . medications on transfer: novolog ss multivit nafcilliln 2g q4h start oseltamivir 90 mg started pantoprazole 40mg iv daily propofol gtt acematinophen 1000mg q6h prn ibuprofen 600mg q8h prn morphine 2mg iv prn ntg sl prn levalbuterol hfa 4 puffs q6hs artifical tears oint q4hs asa 325mg daily chlorhexidien 15ml q12h plavix 75mg daily heparin gtt started . previous meds in osh: enoxaparin 40mg daily start , d/c diltiazem gtt started , d/c levofloxacin 750mg q48h start , d/c digoxin 0.125 x 2 on vancomcyin 1g iv start discharge medications: 1. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day). 2. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 3. metoprolol tartrate 50 mg tablet sig: three (3) tablet po tid (3 times a day). 4. insulin glargine 100 unit/ml solution sig: fifty (50) unit subcutaneous at bedtime. 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal tid prn () as needed for hemorrhoid. 7. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 8. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. magnesium oxide 400 mg tablet sig: 2.5 tablets po bid (2 times a day). 11. humalog 100 unit/ml solution sig: one (1) subcutaneous four times a day: dose based on sliding scale. discharge disposition: extended care facility: state hospital discharge diagnosis: primary diagnoses: - community acquired pneumonia: methicillin sensitive staph aureus pneumonia. - ventilator associated pneumonia: multi-drug-resistant klebsiella and pseudomonas. - bacteremia - septic shock - supra-ventricular tachycardia with aberrancy - intensive care unit myopathy. - acute renal failure - magnesium wasting - encephalopathy - extensive t2/flair hyperintensities deep white matter not otherwise specified - stage ii sacral decubitus ulcer secondary: - diabetes mellitus type ii - hypertension discharge condition: afebrile, satting well on room air. patient is alert, speaking in short sentences and following commands/answering questions. . mental status:clear and coherent level of consciousness:alert and interactive activity status:out of bed with assistance to chair or wheelchair discharge instructions: it was a pleasure to be involved in your care, mr. . you were hospitalized at for septic shock--low blood pressure due to an infection. you had a severe pneumonia (a lung infection) and blood infection, which required placement of a breathing tube, intra-venous antibiotics and a prolonged stay in the medical icu. as a result of your infection, your kidneys gave out, and you required hemodialysis--however, with improvement of your infection, your kidneys function improved and returned to . at times during your hospitalization, your heart rate became very fast and your blood pressure was very elevated--this was treated with medications, and has since resolved. because of prolonged icu stay, your muscle has become very weak, and you need aggressive physical therapy to regain your strength. you also underwent brain mri because you had some confusion after you were extubated. the mri had some abnormalities, likely due to how sick you were. you then underwent a procedure called lumbar puncture to further evaluate these changes noted in mris; no active infection was found. you were also seen by neurology specialists. new medications: --magnesium oxide --colace --multivitamin --linsinopril --pramoxine-minreral oil rectal ointment --clotrimazole --insulin glargine --insulin followup instructions: you have an appointment to follow up with dr. (neurology). date: time: 11:00am location: , bldg. floor 8 please make sure you call patient registration before coming to the appointment( please make an appointment to see your primary care physician . within 1 week of discharge from rehab. make sure you have your blood sugar checked at this visit as you were started on an insulin regimen for diabetes while you were an inpatient. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis arterial catheterization diagnoses: acidosis hyperpotassemia anemia, unspecified acute kidney failure with lesion of tubular necrosis toxic encephalopathy diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation chronic kidney disease, unspecified acute respiratory failure septic shock methicillin susceptible pneumonia due to staphylococcus aureus pressure ulcer, lower back dermatitis due to drugs and medicines taken internally other septicemia due to gram-negative organisms ventilator associated pneumonia other specified antibiotics causing adverse effects in therapeutic use disorders of magnesium metabolism critical illness myopathy paroxysmal supraventricular tachycardia pressure ulcer, stage ii 

Answer: The patient is high likely exposed to