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: penicillins / erythromycin base / heparin agents attending: chief complaint: tracheomalacia major surgical or invasive procedure: : had rigid bronch, electrocautery and balloon dilatation of trachea, and upsizing of her trach to a #7 : rigid bronch, t-tube placement l-picc placement history of present illness: txfer from in , patient was difficult to extubate s/p cabg and required a tracheostomy. she was subsequently sent to pulmonary rehab. . she was referred to dr. in who performed a rigid bronchoscopy here followed by replacement of her tracheostomy tube. she was found to have a circumferential area of stenosis below the cricoid cartilage extending 6cm; it was not felt to be granulation tissue. debridement was minimally successful. a ct scan was done which showed that she had: -focal tracheal stenosis at the inferior extent of the tracheostomy tube. -there was also: proximal narrowing which may relate to granulation tissue versus secretions. -polypoid soft tissue density just above the insertion of the tracheostomy tube may relate to granulation tissue. . - she was discharged back to rehab . on , she was then admitted to with sob and desatted to the low 90s. she was given o2, suctioning and nebulizers without significant improvement. initially, she was started on levoquin and finished a 14 day course for suspected bronchitis. her respiratatory status improved and hence she did not require ventilation. . she was found on hod #2 to have enterococcus bacteremia - via cx x 2 on and cx x 2 on . (a tte was negative for vegetations. a tee was not performed). as such, she was started on vancomycin with subsequent negative surveillance cultures. . : id was consulted. they added on gent once her urine culture came back positive for klebsiella uti. this particular klebsiella uti was only sensitive to gentamicin, imipenem, zosyn and cefotetan. - started on imipenem on for this. . on , she was obtunded and had significant mucous secretions and mucus plugging requiring suctioning; ent changed her cuffless trach from a #6 to a #4 and transitioned to a trach collar after transient ventilation. . on , she has a ij tlc placed in or at . on , noticed to have "mild stridor" and mild tachypnea and was replaced on a ventilator. . of note: - was found to be c diff + and was started on flagyl . today, she is transferred to for further options regarding placement of a new tracheostomy tube. past medical history: 1. cad - s/p ptca , nstemi , s/p cabgx4 (lima->lad, vein grafts to om and distal cflx, reverse saphenous to post descending artery) - s/p sternal wound debridement (proteus and staph) -> id recommended 6 wks of ceftriaxone and vancomycin -> ? if finished - brief episode of afib/aflutter -> amiodarone -> 2nd degree heart block -> converted back to sinus - complicated by: proteus mirabilis sepsis 2. l subdural hematoma ( - s/p fall)with r aneurysm; with r homonymous hemianopsia 3. siadh 4. diabetes mellitus ii 5. aortic valve replacement (bovine) 6. pituitary tumor 7. gerd 8. urinary tract infection; 9. sternal wound infection. 10. s/p tracheostomy for respiratory failure. 10. tracheomalacia -> s/p laser removal of granulation tissue x 2 () 11. c diff colitis 12. renal insufficiency (baseline cr: ? - last cr was 1.5 at ) 13. s/p hysterectomy social history: she presently resides in rehab facility on . son and daughter involved w/ care. does not drink etoh. smoked in past but not at this time. family history: significant for cad in her mother at age of 62. siblings died from heart disease. physical exam: t: 97.9 bp: 114/42 p: 63 resp: cpap + ps : 20 x 425 @ fio2 of 0.3 gen: obese female in nad heent: perrla eomi. op without upper dentition. multiple fillings in lower dentition. neck: large with trach in place and attached to ventilator. cv: +s1+s2 sem heard in multiple fields resp: coarse sounds c/w ventilator. no crackles or wheezing heard abd: midline scar. multiple ecchymoses and bruises from injections. soft nt nd. ext: 2+ pretibial edema. patient with 2 healing ulcers on l leg in region of scars from vein removal for cabg. no splinter hemorrhages seen in finger nails. neuro: aao x 3 pertinent results: reports: . chest (portable ap) 8:17 pm a tracheostomy tube terminates within the trachea just above the level of the clavicles. left internal jugular vascular catheter terminates in the superior vena cava, and a nasogastric tube courses below the diaphragm. cardiac silhouette is enlarged. there are patchy and linear areas of atelectasis at the lung bases. there is a questionable small left pleural effusion. . tee conclusions: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. a bioprosthetic aortic valve prosthesis is present. the aortic prosthesis appears well seated, with thin leaflets that display normal motion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: normal aortic bioprosthesis. mild mitral regurgitation with mildly thickened leaflets. no vegetation seen. . wrist(3 + views) right port 11:52 am impression: 1. no definite evidence for fractures. 2. degenerative changes as described above. . chest port. line placement 8:57 am impression: 1. left-sided picc with tip in svc. findings discussed with of iv therapy at 10:30 a.m. 2. improving opacity in the left perihilar region could represent improving aspiration or asymmetric edema. stable bibasilar atelectasis. . imaging: kub impression: 1) distention of small bowel suggestive of functional colonic abnormality causing small-bowel obstruction. 2) interval decrease in size of transverse colon now measuring 4 cm in widest diameter. . . admission labs: . 10:02pm urine color-straw appear-cloudy sp -1.012 10:02pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 10:02pm urine rbc->50 wbc->50 bacteria-many yeast-many epi-0-2 08:24pm glucose-137* urea n-45* creat-1.5* sodium-145 potassium-3.9 chloride-111* total co2-26 anion gap-12 08:24pm calcium-8.6 phosphate-2.8 magnesium-1.9 08:24pm vanco-10.7* 08:24pm phenytoin-6.7* 08:24pm wbc-19.7*# rbc-3.33* hgb-9.7* hct-29.2* mcv-88 mch-29.1 mchc-33.1 rdw-17.9* 08:24pm neuts-90.6* lymphs-5.8* monos-2.2 eos-1.0 basos-0.2 08:24pm hypochrom-1+ anisocyt-1+ poikilocy-1+ microcyt-1+ 08:24pm plt count-186 08:24pm pt-13.1 ptt-29.3 inr(pt)-1.1 . discharge labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 04:57am 14.6* 3.79* 11.0* 33.1* 87 29.0 33.2 17.9* 264 glucose urean creat na k cl hco3 angap 04:57am 126* 53* 1.6* 134 4.1 106 19* 13 . lfts: alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 05:00pm 15 14 20* 127* 21 0.2 06:03am 6 7 140 97 0.2 lipase 05:00pm 9 . albumin globuln calcium phos mg 10:13am 1.6* 7.2* 3.6 2.2 . heme: caltibc ferritn trf 05:54am 74* 872* 57 . pituitary: prolact tsh 05:54am 107* 2.1 free t4 05:54am 0.6 phenyto 04:00am 3.0 freeca 11:09am 1.19 . . micro: . blood cx: negative 5:30 pm blood culture 2 of 2 negative . 4:10 pm catheter tip-iv source: lij triple lumen. -no growth . . 9:57 pm sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative diplococci. smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. acinetobacter baumannii. moderate growth. "note, for amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". klebsiella pneumoniae. sparse growth. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ acinetobacter baumannii | klebsiella pneumoniae | | ampicillin/sulbactam-- =>32 r =>32 r cefazolin------------- =>64 r cefepime-------------- 16 i r ceftazidime----------- =>64 r =>64 r ceftriaxone----------- r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s 4 s imipenem-------------- =>16 r <=1 s levofloxacin---------- 4 i =>8 r meropenem------------- <=0.25 s piperacillin/tazo----- 8 s tobramycin------------ <=1 s =>16 r trimethoprim/sulfa---- <=1 s <=1 s . c.diff: positive . urine cx: yeast . 12:17 am sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. respiratory culture (final ): sparse growth oropharyngeal flora. acinetobacter baumannii. moderate growth. identification and sensitivities performed on culture # . klebsiella pneumoniae. sparse growth. identification and sensitivities performed on culture # . . urine urine site: clean catch **final report ** urine culture (final ): klebsiella pneumoniae. >100,000 organisms/ml.. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 16 i cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- =>64 r ceftriaxone----------- r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s imipenem-------------- <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s nitrofurantoin-------- 256 r piperacillin/tazo----- 8 s tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r brief hospital course: 67 yo female with history of tracheobronchomalacia transferred from osh for further management. micu course: pt followed by ip, tracheomalacia c/w subglottic granulation tissue and mid trach stenosis. s/p rigid bronch + excision, debridement, dilatation and trach change. she was managed for acinobacter/klebsiella vap, +c-diff and followed by id. tee negative for vegetations. pt back to micu on for aggressive fluid resuscitation given c-diff colitis and poor po intake with metabolic acidosis. was given ivf w/bicarb, following but not surgical candidate given comorbidities, started ivflagyl/po vanco with slowly improving diarrhea. on went into raf, s/p cv now in nsr remains stable. transferred to floor . . # respiratory: **tracheomalacia: this was noted on previous admission to . - s/p laser removal of tissue x 2 in the past - on : was switched from vent to trach mask and tolerated this well - on : had rigid , electrocautery and balloon dilatation of trachea and upsizing of her trach to a #7 -> will need a special long trach which was ordered and will be available on . per ip underwent a trach change with t-tube placement on without complications. her trach was capped with stable o2sats and voice audible. per ip her trach is to be capped during the day and with humidified o2 at night for her osa. if pt needs oxygenation she can be oxygenated with nasal cannula o2 with capped trach. . **acinobacter/klebsiella vap: started bactrim on , completed 14 day course on -- continue mucinex prn mucus buildup -- d/cd atrovent, albuterol standing nebs -- pt was on solumedrol 60 iv bid prior to admission (unclear reason why, ? copd flare), and pt was started on taper on and completed taper without any difficulties . # id: pt had hx of enteroccus bacteremia, which was believed to be treated adequately with 23 day course of vanc at osh. she had a tee here, which was negative for vegetation, per id recommendations the vanc was d/c'd. surveillance cx's were ngtd. pt grew acinetobacter from her sputum, and was started on bactrim on for 14 day course for vent associated pna. pt also had hx of klebsiella uti, and had been treated with imipenem at osh. per id recommendations, pt was likely colonized from frequent foley catheterizations, and imipenem was d/c'd. pt had dirty ua on admission here, but urine cx only grew yeast. attempted to contact to obtain records of antimicrobial succeptibilities of sternal infections and bacteremias in past. sternal wound infection was staph and proteus per surgical summary. however, they did not send the micro data, so will need to call the micro lab at some point in the future for further information. pt had hx of c.dif, and was continued on flagyl for additional 14 day course. pt had low grade temps during her micu stay (with a tmax of 100.5), but did not have a significant temp spike. she then had explosive diarrhea with +c-diff in stools. she had persistent diarrhea, resistent to po flagyl treatment, she was started on po vanco as well as iv flagyl on for c-diff colitis. id again reconsulted for persistent diarrhea and elevated wbc. her diarrhea improved with po vanco and ivflagyl, her wbc peaked at 29 and came down to 14.4 at time of discharge. she was also started on meropenem on for klebsiella uti. per id she was to continue po vanco/flagyl until all other antibiotics d/c'd and diarrhea improved. she remained afebrile with improving wbc and no new culture data. she will complete a recommended 10day course of meropenem on . she remained afebrile with improving wbc and no new culture data at time of discharge. . #. c-diff colitis: pt with explosive diarrhea treated for c-diff as noted above. she was followed closely by surgery, however given her other comorbidities she was not a surgical candidate. she was followed with daily kubs, her last kub notable for improvement in loops of bowel size. however, notable for small bowel obstruction on . pt was kept on a clear liquid diet with plan to advance when improved colities. her stool output improved at time of discharge. continued c-diff precuations. . # neuro: seizure prophylaxis - on phenytoin (likely since she had subdural sustained in ) - continued phenytoin during this admission, increased dose given low albumin and subtherapeutic with corrected dose. changed dose from 200mgqam to 300mg qam and increased 300mg qpm to 400mgqpm. she did not have any siezure activity while hospitalized. - ct from osh revealed mass in supracisternal region on r and patient notes that she has had changes in vision in her r eye - specificially she notes seeing random objects since her fall. pt had r homonymous hemianopsia and was to follow up with neuroopthamology. - : contact dr. (endocrine at ) regarding her pituitary tumor. restarted her on carbergoline for her prolactinoma. per dr. should reckeck prolactin levels in 6 weeks since prolactin levels elevated during this admission. plan to continue cabergoline at current dose 0.5mg 2x/week. if her prolactin levels are persistently elevated may increase dose 0.75mg 2x/week. - pituitary tumor is a prolactinoma and measures approx 5cm x 2.5cm x 3cm . # renal: - cr 1.5 on admission; this is similar to level when she left - renally dose medications -> increaed cr on with peak to 2.4 due to poor po intake and explosive diarrhea. renal followed pt, found no muddy brown casts, arf c/w prerenal etiology also atn in setting of poor forward flow. she was agressively hydrated in the micu with addition of 50meq nahco3. her arf improved with cr. decreased to 1.6 at time of discharge. her ivf were discontinued on as she was significantly volume overloaded and making urine, although poorly ~700cc per day. . #. metabolic acidosis: pt with explosive diarrhea with low bicarb. she was started on 50meq nahco3w/1000ml 1/2ns to manage metabolic acidosis. her hco3 improved, her hypernatremia corrected. however, she also developed hyponatremia with ivf resuscitation. her ivf were d/c'd on , her hco3 at time of discharge was 19. . # cardio: pt s/p cabg in the past, she also went into aflutter for which she was cardioverted on . she remained in nsr. she did not tolerate a bb throughout her hospital course due to hypotension. she was continued on an asa and statin. no other antihypertensive medication was added to her medical regimen. her sbp was stable at time of discharge sbp 115. d/c'd hctz during this admission, due to borderline low bp and likely need for bb in the future . # dm2: her bs was persistently elevated while she was on steroids. she was maintained on an iss which was titrated for better bs control. check fs qid . # gerd: continued ppi . # : ppi, fondaparinaux for dvt (pt has hx of hit). however fondaparinaux was held prior to ip procedure, but was restarted s/p procedure. head of bed at 30 degress . # fen: pt grossly volume overloaded. allow pt to autodierese and holding further ivf. currenlty receiving tpn since poor po intake; clear liquid diet until colitis improved. note on : had fees study by speech/swallow team -> ok to have nectar thick liquids and ground solids, however changed diet to clear liq due to colitis. will need a new nutrition evaluation at to advance diet. . # access: l subclavian - placed in or on at - removed on with no growth on culture data - switched picc on because patient has hit. hence switched to picc which does not require heparin. . # code status: dnr/dni. evolving discussions with hcp cell home medications on admission: # flagyl 250mg po qid # pantoprazole 40 mg iv daily # clonzepam: 0.5mg # albuterol sulfate (1) neb q6h:prn # ipratropium bromide (1) neb q6h: prn # mvi daily # fondaparinux 2.5mg sc daily # solumedrol 60mg iv bid # guaifenasin 600mg ng qid # ranitidine 150mg po bid # phenytoin sodium : 200mg qam, 300mg qpm # ativan: 0.5mg -1mg q6 prn # hydrochlorothiazide 75 mg daily # fe so4 325mg po daily (daily). # colace 100mg qam and :prn # tylenol prn # insulin ss # acetylcysteine: 200mg q4:prn # vancomycin: 1g iv q48 # nystatin powder to groin # epoetin alfa units qmowefr (monday -wednesday-friday). # imipenem: 250mg q6hr # was on carbergoline 0.5mg qtue, qfri discharge medications: 1. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 2. acetaminophen 160 mg/5 ml solution sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 3. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 4. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 5. epoetin alfa 10,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 6. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 7. phenol-phenolate sodium 1.4 % mouthwash sig: one (1) spray mucous membrane q6h (every 6 hours) as needed. 8. ipratropium bromide 17 mcg/actuation aerosol sig: 2-6 puffs inhalation q4-6h (every 4 to 6 hours) as needed. 9. cabergoline 0.5 mg tablet sig: one (1) tablet po qtues, qfriday (). 10. fondaparinux 2.5 mg/0.5 ml syringe sig: one (1) subcutaneous daily (daily). 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. vancomycin 250 mg capsule sig: one (1) capsule po q6h (every 6 hours). 13. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 14. phenytoin sodium extended 100 mg capsule sig: four (4) capsule po qpm (once a day (in the evening)). 15. phenytoin sodium extended 100 mg capsule sig: three (3) capsule po qam (once a day (in the morning)). 16. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day). 17. lidocaine hcl 0.5 % solution sig: one (1) ml injection q1h (every hour) as needed for cough. 18. lidocaine hcl 1 % solution sig: one (1) ml injection q1-2h () as needed. 19. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 20. lorazepam 0.5-1 mg iv q6h:prn 21. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours): will complete 10 day course on . 22. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: discharge diagnosis: primary: tracheomalacia and stenosis mdr klebsiella uti c. difficile colitis toxic megacolon high output diarrhea acute tubular necrosis secondary to hypovolemia acinetobacter/klebsiella vap enterococcal/klebsiella bactermia (prior to admission) anasarca malnutrition-severe af w/rvr s/p cardioversion . secondary: coronary artery disease s/p cabg x 4 bioprosthetic aortic valve replacement sternal wound infection perioperative paroxsmal atrial fibrillation left subdural hematoma s/p fall - r homonymous hemianopsia siadh diabetes mellitus type ii pituitary tumor - prolactinoma, on seizure prophylaxis morbid obesity chronic kidney disease cr~1.5 heparin induced thrombocytopenia (hit) discharge condition: stable discharge instructions: please take all your medications as directed. . always cap trach during the day and humidified oxygen at night for osa, please see instruction for trach care noted below to prevent mucous plugging . site: anterior lle type: leg ulcer cleansing : saline change dressing: comment: aquacel dressing . continue pressure relief measures - air bed-low air loss bed -turn and reposition every 1-2hours off back -heels off bed surface at all times . cleanse trach site with ns, pat dry --apply no sting barrier wipe to irritated skin, air dry --apply allevyn foam trach sponges around trach, change every 2-3days prn . t-tube care: -keep cap at all times, use nasal canula for oxygenation -apply 204ml of ns q12hours to prevent mucous plugging -if need to uncap use humidified o2 at all times followup instructions: follow up with dr. in 4 weeks at bronch unit at , please call if you have further questions at (. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances other electric countershock of heart other operations on trachea replacement of tracheostomy tube local excision or destruction of lesion or tissue of trachea tracheoscopy through artificial stoma diagnoses: acidosis pneumonia due to other gram-negative bacteria acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified unspecified septicemia severe sepsis atrial fibrillation aortocoronary bypass status chronic kidney disease, unspecified intestinal infection due to clostridium difficile anticoagulants causing adverse effects in therapeutic use heart valve replaced by transplant ulcerative colitis, unspecified hypovolemia other disorders of neurohypophysis pneumonia due to klebsiella pneumoniae chronic respiratory failure nutritional marasmus mechanical complication of tracheostomy stenosis of larynx non-healing surgical wound infection with microorganisms with resistance to multiple drugs homonymous bilateral field defects benign neoplasm of pituitary gland and craniopharyngeal duct 

Answer: The patient is high likely exposed to