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: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: central veinous line placement picc placement history of present illness: this is a 68m t4 level paraplejia, cad, chf ef , severe sacral debub, multiple utis, pe with ivc filter who is sent from rehab with hypotension. of note, recently discharged from after and admission for code stroke -- which at the end, it was thought to be a seizure episode. prior to that, admitted - for fever and hypotension treated for uti and wound infection with vanc/zosyn compleatted on . . sent to the ed, after he was noted hypotensive today into the 60's.per referal, he was noted with bo into the 60's that did not repond to fluid boluses. per report, his baseline bp 80-90's. he had also been currently treated with antibiotics for a uti. he completely his vancomycin/zosyn treatment course for enterococi uti and decub/ulcer swab infection on . . in the ed, vs: he was hypotensive into the 60's, good mental status. a ij line was placed and levophed was started. levophed was also started. id was curvesided and agreed with vanc/zosyn for empiric coverage . ros: denied fever, chills, sob, cough, chest pain, abdominal pain, blood in stools, weight gain or weight loss social history: he moved here from (after living in many different countries) in the . he is retired from a job in the maritime industry. divorced 24 years ago. three children. quit smoking . quit drinking . no history of illicit drug use or abuse. family history: no stroke, aneurysm, no seizure, no aaa. pertinent results: admit labs: 01:25pm blood wbc-9.4# rbc-3.52* hgb-8.7* hct-28.1* mcv-80* mch-24.8* mchc-31.1 rdw-17.0* 01:25pm blood pt-26.6* ptt-38.4* inr(pt)-2.7* 01:25pm blood glucose-101 urean-15 creat-1.1 na-139 k-4.7 cl-104 hco3-24 angap-16 01:25pm blood alt-5 ast-10 ld(ldh)-124 ck(cpk)-50 alkphos-89 totbili-0.2 01:25pm blood albumin-2.8* calcium-8.6 phos-2.3* mg-1.6 04:00am blood cortsol-14.0 ================================================= discharge labs: 03:19am blood wbc-6.3 rbc-3.17* hgb-7.7* hct-25.5* mcv-81* mch-24.2* mchc-30.1* rdw-17.6* plt ct-146* 03:19am blood plt ct-146* 03:19am blood pt-29.5* ptt-37.4* inr(pt)-3.0* 03:19am blood glucose-79 urean-5* creat-0.5 na-140 k-3.9 cl-109* hco3-24 angap-11 05:50am blood alt-6 ast-9 alkphos-78 amylase-46 totbili-0.2 03:19am blood mg-1.7 cholesterol: 05:40am blood triglyc-79 hdl-18 chol/hd-3.1 ldlcalc-21 05:40am blood cholest-55 ========================================================== ecg:sinus rhythm. prior inferior myocardial infarction. diffuse non-specific st-t wave changes. compared to the previous tracing of there is diffuse st segment and t wave flattening. otherwise, no diagnostic interim change. ========================================================== chest (portable ap); -77 by different physician reason: infiltrate? pneumothorax? medical condition: 68 year old man with urosepsis, s/p hypoxia and coughing, increased o2 requirement reason for this examination: infiltrate? pneumothorax? ap chest 8:45 p.m. history: hypoxia and coughing. possible pneumothorax. impression: ap chest compared to through : lungs are clear. heart size normal. no pneumothorax or pleural effusion. the patient has had median sternotomy. tip of the right jugular line projects over the upper svc. no pneumothorax. ============================================================== mr w & w/o contrast 8:23 am mr w & w/o contrast reason: please evalaute l-spine/coccyx--patient with multiple sacral contrast: magnevist medical condition: 68 year old man with t4 paraplegia, multiple sacral decub include probe to bone- admit with sepsis-unclear source reason for this examination: please evalaute l-spine/coccyx--patient with multiple sacral decubitus ulcers, sepsis unclear source--?osteomyelitis contraindications for iv contrast: none. indication: t4 paraplegia with multiple sacral decubitus ulcers probing to bone. admitted with sepsis of unclear source. please evaluate for osteomyelitis. technique: multiplanar t1- and t2-weighted images were obtained through the lumbar spine without and with intravenous contrast. comparison: mr lumbar spine images of . mr lumbar spine without and with contrast: sagittal images were obtained through the lumbosacral spine; however, axial images go through s1-s2. there is no evidence of lumbar spine fracture or malalignment. at l2-l3 and l3-l4, there is no evidence of significant canal stenosis or neural foraminal narrowing. at l4-l5, there are degenerative endplate changes consistent with type 2 changes. there is mild loss of disc height with mild-to-moderate left and moderate right neural foraminal narrowing without significant canal stenosis. at l5-s1, there are type 2 degenerative changes of the endplates with mild loss of the vertebral body and disc space height. a mild central disc bulge is again noted along with mild bilateral facet hypertrophy causing moderate left and mild-to-moderate right neural foraminal narrowing. there has been no change in the signal intensity within the lumbosacral spine since the prior exam. there is no abnormal enhancement. there is no evidence of osteomyelitis. there is marked atrophy of the conus of the spinal cord as well as the paraspinal musculature consistent with the patient's history of paraplegia. impression: 1. no evidence of osteomyelitis within the lumbar spine and visualized portion of the sacrum. 2. multilevel degenerative changes as described above without high-grade spinal canal stenosis. 3. atrophy of the conus of the spinal cord and paraspinal muscles consistent with paraplegia ============================================================= brief hospital course: 68m t4 paraplegia, cad, systolic chf, sacral decubitus ulcers, multiple utis, pe with ivc filter on anticoagulation admitted with hypotension. . # hypotension/septicemia: pt (chronic nursing home pt) was considered to have multiple possible sources of infection including lines, urosepsis, and decubitus ulcers. pt was started on vancomycin for mrsa, meropenem for pseudomonas, ciprofloxacin for double gnr coverage, and metronidazole for anaerobic coverage. of note, had been on levoquin and flagyl for unclear reasons at rehab for sometime before admission to . aggressive fluid rescucitation and pressors in icu. pt was taken off pressors two days after admission, and remained afebrile throughout. picc line removed, foley catheter changed. blood, urine, and midline cultures remained no growth throughout but were of little value given antibiotic therapy preceding cultures. plastic surgery evaluated sacral decubs and did not feel they were likely source of sepsis. mri of sacral decubs without evidence of sepsis. c. diff considered, no samples sent in icu and then on floor, no stool for sample. influenza negative. appropriate adrenal response on stim testing. patient to receive two week course of vancomycin/meropenem given septicemia without source. he should receive flagyl for one week after completion of these given high risk for c. diff and possible c. diff as cause of septicemia. needs safety labs including cbc, chem-10, lft's . 7more days vanc/meropenm and 14 days flagyl. ********please note, after this course, patient should have serial blood cultures, urine cultures and evaluation/wound culture by plastic surgery as he has had multiple admissions for septicemia of unclear etiology. he should not be treated empirically with antibiotics unless these cultures are performed or unless he is critically ill, precluding the ability to obtain these cultures. it is strongly suspected that his decubitus ulcers may be leading to these episodes, but almost chronic institution of antibiotics without culture data precludes definitive treatment. furthermore, patient has baseline low blood pressure from chronic systolic heart failure and possible autonomic dysregulation. on discharge, bp 80's to 100's on low dose lisinopril and carvedilol . # decubitus ulcer: pt was noted to have extensive decubitus ulcers, and plastics as well as wound care were consulted. wound care recs were followed; plastics did not feel further imaging or tissue sampling was warranted. mri was obtained and did not demonstrate osteomyelitis. . chronic systolic heart failure: ef 25%. with aggressive fluids/pressors, no pulmonary edema. low dose lisinopril and carvedilol re-started by . bp's generally 80's to 100's. . coronary artery disease: no specific ischemic changes on ecg. maintained on aspirin. beta blocker and ace inhibitor added by discharge. statin discontinued as cholesterol very low (total of 55). . # pe s/p ivc filter: pt's warfarin was initially held given inr 3.5; anticoagulation dosing was per inr with goal between 2 and 3. on day of d/c, inr of 2.9, plan 1mg coumadin today. should have inr check on and then week of . . # depression: continued citalopram . # h/o seizures: continued keppra . # h/o cholelitiasis/abdominal pain/gerd: patient with intermittent complaints of ruq and epigastric abdominal pain, also left sided chest.. ppi changed to , tums and maalox added. lft's within normal limits on serial measurements. ruq u/s showed large stone in gallbladder which has been seen previously, no evidence choleycystitis continued ursodiol throughout. if ongoing pain, patietn should be evaluated by surgery once he has completed his antibioitic course for consideration of choleycystectomy . medications on admission: ipratropium q8h levetiracetam 500 levofloxacine 250 daily megace 400 mg once daily metronidazol 500 mg tid / -- apparently after debridment. omeprazole 20 mg daily ondansetron 4 mg q8h oxycodone 5 mg tid potassium 20 meq senna 1 tab ursodiol 300 mg warfarin 0.5 mg inr 2.3 albuterol 2 puff q6h aspirin 81 daily baclofen 10 mg tid bisacodyl 10 mg once daily calcium carbonate 650 tid carvedilol 3.125 citalopram 30 mg qd fluticasone/salmeterol advair 250/50 gabapentin 300 insulin sliding scale prn tylenol 650 q4h maalox prochlorperazine 25 mg q12 rectall discharge medications: 1. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 3. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 4. baclofen 10 mg tablet sig: 0.5 tablet po tid (3 times a day). 5. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 6. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 8. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 9. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). 12. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 13. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 14. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 16. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 17. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 18. warfarin 1 mg tablet sig: one (1) tablet po once for 1 doses: on . 19. warfarin 2 mg tablet sig: one (1) tablet po once a day: must have inr check on and goal inr is . 20. meropenem 500 mg recon soln sig: five hundred (500) mg recon soln intravenous q6h (every 6 hours) for 7 days. 21. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 7 days. 22. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 14 days. 23. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for gas. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: 1. septicemia, nos 2. chronic systolic heart failure 3. coronary artery disease 4. pulmonary embolism 5. paraplegia 6. sacral decubitus ulcer 7. gerd 8. choledocholithiasis without obstruction 9. anemia 10. seizure history discharge condition: afebrile, stable, tolerating po intake, systolic bp 80-100 discharge instructions: adhere to 2 gm sodium diet fluid restriction:2 liters . all medications as prescribed. we have made a number of changes. please note patient to receive coumadin 1mg on for inr of 2.9 and then to resume coumadin therapy on . should have inr checked on to guide further therapy (had been getting 2mg daily but now on multiple antibiotics). goal inr is between 2 and 3. usual dose will likely need to be altered given concurrent vancomycin/meropenem/flagyl therapy. patient's systolic blood pressure generally between 80 and 100. patient should receive lisinopril and carvedilol unless bp drops below eighty given his heart failure. once patient completes antibiotic course, should have blood cultures sent and be seen by plastic surgery. he has had a number of admissions for sepsis of unclear etiology. he should not be treated with empiric antibiotics before having blood, urine and wound cultures sent unless he is critically ill. patient should have inr checked on and then during week of to guide coumadin therapy. patient should have full set of safety labs checked including cbc, chem-10, alt, ast, total bilirubin. patient has ongoing right upper quadrant/right sided chest pain. it has been extesnively worked up. he does have gallstones but no evidence of choleycystitis. if this is ongoing, he should be evaluated by a surgeon once he has finished his antibiotic course. follow up as below. followup instructions: patient should follow up with primary care doctor within two weeks of discharge from rehab. you will be followed by doctors there in the meantime. you should follow up with plastic surgery here at after completing your antibiotic course. you also have the previously scheduled appointments: neurology: provider: , md phone: date/time: 9:30 cardiology: provider: , . phone: date/time: 9:40 provider: phone: date/time: 11:00 procedure: venous catheterization, not elsewhere classified diagnoses: esophageal reflux congestive heart failure, unspecified unspecified septicemia severe sepsis chronic airway obstruction, not elsewhere classified septic shock pressure ulcer, buttock pressure ulcer, lower back personal history of venous thrombosis and embolism acute systolic heart failure paraplegia pressure ulcer, hip 

Answer: The patient is high likely exposed to