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 / estrogens / ancef / tegretol / keflex attending: chief complaint: hypotension major surgical or invasive procedure: nephrostomy tube placement history of present illness: 47 yo f w/ h/o steroid-induced hyperglycemia, sle w/ h/o pericarditis, transverse myelitis w/ paraplegia and neurogenic bladder s/p urostomy w/ ileal conduit, h/o ureteropelvic stone and urosepsis, and h/o rle dvt a/w f transferred to micu for hypotn resistant to ivfs and stress steroids. patient initially p/w c/o sudden onset n/abd pain/chills w/ t 103 at nh. rigors progressed so she was brought to ed. she reported h/o fatigue and anorexia for the past few days and had noticed foul smelling urine and some abdominal distension, similar to prior episodes of pyelo. she also c/o llq and groin pain which responded to tylenol. she denies v or d. no ams. no c/o cp. on arrival to ed, temperature was 101.2. ct abd showed an 8 mm right proximal ureteral stone with right-sided hydronephrosis and inflammatory stranding, in addition to pyelonephritis of the left kidney without left sided hydronephrosis. labs were remarkable for wbc 23.5 w/ 1% bands which decreased to 14 today but now w/ 15% bands on vanc (h/o mrsa urosepsis) and gent (mult drug allergies). ag on admission 18 (bicarb 17, down from 23 on a previous admission), down to ag 15 this am. abg prior to transfer (on room air): 7.43/24/69 w/ lactate 1.3 (down from 1.4 on the prior day). currently, blood cx are growing gnr in both anaerobic bottles. urine cx is pending. prior to transfer, patient dropped bp to 68/40s. bp did not improve despite 2 l ns and 100 mg iv hydrocortisone. a central line was placed and she was sent to ir for a right nephrostomy tube. past medical history: ## h/o nephrolithiasis s/p lithotripsy and h/o left ureteropelvic junction stone ' spontaneously passing by u/s, no evidence of right stone on most recent u/s 5 months ago ## h/o pyelo, last episode in ' (mrsa in blood and urine) ## sle w/ h/o pericarditis, last flare couple years ago, didn't flare w/ urosepsis ## devic's disease: recurrent transverse myelitis with sequelae of paraplegia-exacerbation in 93 recurrent bilateral optic neuritis with legal (neurologist: dr. , ) - (steroids increased to 40 qd in for concern for recurrent optic neuritis which turned out to be capsular ossification) ## blindness in right eye. ## bilateral knee arthritis ## suspected glaucoma in left eye, turned out to be capsular ossification or a secondary cataract, corrected w/ laser surgery ## urostomy s/p ileal loop conduit in for neurogenic bladder w/ persistent leak ## steroid-induced hyperglycemia ## hypothyroid ## osteoporosis ## hx of dvt in rle ' - on coumadin for a couple years and then asa until a couple months ago social history: retired icu nurse. x 15 yrs but maintains her certification. lives at home nh x 11 yrs due to chronic med issues. her doctor there is dr. . no h/o tobacco, alcohol, or ivda. wheelchair dependent + requires lift. ue strength intact but poor motor movements due to loss of sensation. family history: mother died at 51 metastatic father died at 36 aplastic anemia only child physical exam: t 100.0 bp 109/56 cvp 11 hr 113 rr 16 o2 95% on 3l nc mixed 82% genrl: in nad, resting comfortably heent: perrla (4->3 mm) bilaterally, blind in right visual field, eomi, dry mm, ? thrush neck: no bruits cv: rrr, no m/r/g, faint s1/s2 pulm: cta bilaterally abd: midline scar (from urostomy), nabs, soft, appears distended but patient denies, ostomy rlq c/d/i, nt to palpation back: right flank urostomy tube, c/d/i, nt to palpation extr: no neuro: a, ox3, wiggles toes bilaterally, unable to lift le, grip bilaterally w/ ue, decrease sensation to soft touch in left ue and le pertinent results: 05:11pm wbc-23.5*# rbc-3.81* hgb-9.4* hct-29.2* mcv-77*# mch-24.6*# mchc-32.1 rdw-18.1* 05:11pm neuts-93* bands-1 lymphs-0 monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 05:11pm glucose-229* urea n-25* creat-0.8 sodium-136 potassium-5.3* chloride-101 total co2-17* anion gap-23* 05:11pm ld(ldh)-214 06:41pm lactate-1.4 05:11pm urine color-straw appear-hazy sp -1.008 05:11pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-9.0* leuk-sm 05:11pm urine rbc-21-50* wbc- bacteria-many yeast-none epi-0-2 05:11pm urine 3phosphat-occ ct cap: 1. an 8 x 7 x 7 mm stone in the proximal right ureter with associated right hydronephrosis and inflammatory perinephric stranding. additional smaller non-obstructing right renal stones. 2. left renal stones without evidence of hydronephrosis. ileal conduit is not well evaluated. 3. right breast calcification. correlation with mammography is suggested. . cxr: no evidence of pneumonia. . ct ap #2 (with contrast): 1. eight mm right proximal ureteral stone with right-sided hydronephrosis and inflammatory stranding. pyelonephritis of the left kidney without left sided hydronephrosis. 2. no evidence of intraabdominal abscess or of diverticulitis. 3. bilateral round, hypodense renal lesions, too small to accurately characterize but likely representing cysts. 4. 1.4 cm hypodense lesion in right lobe of the liver is incompletely characterized. . ct cap: 1. nephrostomy tube in the right kidney with an 8 mm right ureteric stone. 2. 6 mm nonobstructing calculus in the left kidney. 3. calcified focus and a small hypodense lesion in the right lobe of the liver, incompletely characterized. 4. bibasilar and dependent atelectasis. . 5:10 pm blood culture 2. **final report ** aerobic bottle (final ): klebsiella pneumoniae. identification and sensitivities performed from anaerobic bottle. of two colonial morphologies. anaerobic bottle (final ): reported by phone to 10:35a. klebsiella pneumoniae. final sensitivities. trimethoprim/sulfa sensitivity testing available on request. klebsiella pneumoniae. final sensitivities. trimethoprim/sulfa sensitivity testing available on request. 2nd strain. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | klebsiella pneumoniae | | ampicillin/sulbactam-- =>32 r =>32 r cefazolin------------- <=4 s <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ 4 s 4 s ciprofloxacin--------- =>4 r =>4 r gentamicin------------ 8 i 8 i imipenem-------------- <=1 s <=1 s levofloxacin---------- =>8 r =>8 r meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ 4 s 8 i . 1:50 pm urine,kidney perc.neph.. **final report ** fluid culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). staph aureus coag +. >100,000 organisms/ml.. of two colonial morphologies. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. gram negative rod(s). >100,000 organisms/ml.. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | gentamicin------------ =>16 r levofloxacin---------- =>8 r nitrofurantoin-------- <=16 s oxacillin------------- =>4 r penicillin------------ =>0.5 r tetracycline---------- =>16 r vancomycin------------ <=1 s . blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending urine urine culture-final no growth catheter tip-iv wound culture-final no growth blood culture aerobic bottle-pending; anaerobic bottle-pending brief hospital course: 47 yo f w/ h/o steroid-induced hyperglycemia, sle w/ h/o pericarditis, transverse myelitis w/ paraplegia and neurogenic bladder s/p urostomy w/ ileal conduit, h/o ureteropelvic stone and urosepsis, and h/o rle dvt admitted w/ left pyelo and right 8 mm proximal ureteral stone w/ right hydro s/p perc urostomy tube to relieve right hydro. . ## gnr sepsis: upon admission, pt was febrile to 101.2 with u/a consistent with uti. a ct abd showed 8mm obstructing stone, hydro with stranding consistent with pylonephritis. her presentation was thought likely due to urosepsis given h/o foul smelling urine and in setting of stone w/ hydro + pyelo by ct. the patient went to ir on given evidence of right hydronephrosis on imaging for decompression and drainage. upon admission, she was treated with vancomycin and gentamycin and flagyl. she was started on the must protocol with high dose steroids as well and a goal svo2 >70%. she was hypoxic requiring 3l nasal cannula o2. she subsequently developed hypotension with sbp in the 70s. she was transferred to the micu where the patient was continued on the must protocol with goais of cvp 10-12, svo2 greater than 70%. the patient was bolused with ns and did not required pressors. on the day after admission to the micu, the patient was noted to have small oxygen requirement with 2l nc. repeat imaging revealed evidence of mild pulmonary congestion which was thought to account for the patient's mild hypoxia. given that the patient had been maintaining a map of 60 without fluids or pressors, her goal cvp was decreased to >8 to avoid fluid overload. the patient was continued on vancomycin and gentamycin while speciation and sensitivities were pending. ciprofloxacin was added on for synergy when surveillance cultures were found to be growing again gnr. gent and cipro were then discontinued and changed to meropenem when blood culture sensitivities became available revealing gnr sensitive to but resistant to both gent and cipro. additionaly surveillance cultures were drawn daily and the patient was transferred back to the floor with no subsequent pressor requirement. blood cltures from grew klebsiella pneumoniae and grew klebsiella pneumoniae and proteus mirabilis both sensitive to the meropenam which she had already been receiving. urine cultures from grew staph aureus coag +, and gram negative rods of two morphologies (not further speciated). she defervesed by and remained clinically stable with normal blood pressures until the day of discharge. at the time of discharge, blood cultures from and have no growth to date. she received a midline on with a goal of 16 days of further antibiotic treatment with meropenam (for a total of 3 weeks) upon discharge back to the nursing home where she lives. . ## right hydronephrosis: given right sided hydronephrosis and gnr bactermeia, a percutaneous nephrostomy tube was placed by ir . the patient put out 1385 cc urine the day after placement, 950 cc of which came from nephrostomy tube. the tube appeared to be functioning well, draining urine with occasional clot passage. urology was notified about the clots and occasional blood tinged urine but they did not make any further recommendations. cultures from urine drawn from the nephrostomy tube are currently growing > 100k gnr, possibly of two colony morphologies, speciation and sensitivity pending. . ## hct drop: on admission to hospital patient had hct of 29.2. in the setting of right sublavian line placement as well as nephrostomy tube placement the patient was noted to have a drifting hct, concerning for bleed, with nadir of 22.8 on . a ct abdomen was performed which did not demonstrate any retroperitoneal bleed. hct stabilized to 24 for three days prior to discharge. this can be followed as an outpatient. anemia workup revealed a picture of anemia of chronic disease (tibc 225, b12 and folate normal, hapto 397, ferritin 51, trf 173, iron 35). . ## hypoxia: the patient on admission was requiring 3 l nc in the setting of receiving 2l ns and chest film which demonstrated pulmonary congestion. the patient was not diuresed but allowed to auto-diurese any additional fluids and is currently with o2 sats 97-98% on room air. as her bp remained stable she did not receiving any standing fluids but was be bolused as appropriate for a map < 60 or cvp < 8 with careful monitoring of pulmonary status. patient had an echocardiogram in which demonstrated an ef of 60-65%. her o2 requirement by discharge was 96% on room air with no sob. . ## steroid-induced hyperglycemia: at home, the patient received metformin and ssi. the patient's metformin was held and she has been maintained on ssi qid while in the micu. as the patient appeared to be clinically stable, her stress dose steroids were discontinued and the patient was changed back to her home dose of prednisone 40mg po qd for maintenance with anticipated decrease in her blood sugars. her metformin was re-added 2 days prior to discharge as well and fingerstick glucoses on the day of discharge were 93 and 156, respectively. . ## hypothyroidism: repeat tsh and free t4 were appropriate on current outpatient regimen. patient was continued on levothyroxine 75mcg po qd. . ## h/o transverse myelitis/optic neuritis: on stress dose steroids originally given must protocol and sepsis, as patient clinically stabilized, she was changed back to home dose of prednisone 40mg po qd. . ## sle: currently no sx of active disease. no manifestations of sle during this admission. . # osteoporosis- we continued actonel/vit d, tums . ## capsular ossification: we continued eye gtt. . ## fen: she had a low bicarb likely due to renal wasting but there is an anion gap present. serum acetone was normal. we followed lactate while she was in the micu which was normal. she was npo periodically but maintained a normal diet prior to discharge. . # ppx- sq heparin during this admission, ppi . ## communication: patient . ## dispo: to nursing home for follow up with dr. (urology) this coming monday, at 1:30pm and with her pcp at the nursing home medications on admission: home meds: ascorbic acid 500 tid cranberry extract 425 bisacodyl 10mg senna dephenhydramine 50mg prn loperamide prn famotidine 20mg kcl 20mg qd metformin 1000 qd tums 1500 mvi timolol 1 drop 0.5% l eye synthroid 75 qd compro 25mg pr citrucel vitamin d 50k qmondays oxazepam 15mg qhs tizamidine 8mg qhs actonel 35 qwed diovan 80 qd prednisone 40 qd bactrim ds qmwf baclofen pump 2-3yrs insulin ss . meds on transfer: actonel 35 mg oral qwednesdays ascorbic acid 500 mg po tid sodium polystyrene sulfonate 15 gm po once @ 2201 famotidine 20 mg po daily sulfameth/trimethoprim ds 1 tab po qmowefr gentamicin 80 mg iv q8h timolol maleate 0.5% 1 drop os heparin 5000 unit sc tid tizanidine hcl 8 mg po qhs hydrocortisone na succ. 100 mg iv q8h @ 0906 valsartan 80 mg po daily insulin sc (per insulin flowsheet) vancomycin hcl 1000 mg iv q 12h levothyroxine sodium 75 mcg po daily vitamin d 50,000 unit po qwednesdays discharge disposition: extended care facility: home - discharge diagnosis: gnr sepsis; steroid induced hyperglycemia; hydronephrosis; sle discharge condition: stable discharge instructions: pls take all meds as prescribed. call your doctor immediately if any new symptoms develop including fevers, rash, increase in bloody urine in nephrostomy or urostomy bags, etc. follow up appointments listed below. followup instructions: with dr. , , on monday at @ 1:30pm (you also have an appointment scheduled with dr. for ). . provider: phone: date/time: 8:30 procedure: venous catheterization, not elsewhere classified percutaneous nephrostomy without fragmentation diagnoses: systemic lupus erythematosus anemia, unspecified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism unspecified glaucoma sepsis osteoporosis, unspecified other septicemia due to gram-negative organisms personal history of venous thrombosis and embolism hydronephrosis unspecified causes of encephalitis, myelitis, and encephalomyelitis pyelonephritis, unspecified other artificial opening of urinary tract status neuromyelitis optica 

Answer: The patient is high likely exposed to