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: ativan attending: chief complaint: chief complaint: back pain reason for micu admission: altered mental status and epidural abscesses. major surgical or invasive procedure: emg/ncs . lumbar puncture . cervical and thoracic spinal abscess debridement 1. c7 corpectomy. 2. c5-c6 anterior cervical diskectomy and fusion with application of interbody device. 3. biopsy as well as culture of abscess - deep down to the bone and spinal cord. 4. application of interbody device, c7 expandable cage. 5. application of - tongs with removal as well as tongs with removal. 6. posterior spinal decompression, c4 to t1. 7. posterior spinal arthrodesis, c4 to t1. 8. application of local autograft and allograft. 9. t3-t4 posterior decompression for abscess. . l5-s2 spinal abscess debridement 1. iliac crest aspirate. 2. iliac crest bone biopsy. 3. l5 bilateral laminectomy, medial facetectomy, foraminotomy for removal of epidural abscess. 4. s1 bilateral laminectomy, medial facetectomy and decompression for epidural abscess. 5. s2 decompression, bilateral laminectomy. 6. repair of dural leak. . percutaneous gastrojejunostomy tube placement history of present illness: 65f with history of sciatica and chronic low back pain, presenting to hospital with worsening back pain, now admit to micu with altered mental status, renal failure and multiple epidural abcesses. she began to feel ill one week ago when she acutely felt "awful" with low-grade fevers, back pain and thought she had the flu. she went to the ed, where she was treated with ibuprofen, vicodin and tamiflu. she stayed home for the rest of the week resting her back, until the pain worsened on friday and she went to see her pcp. was diagnosed with sciatica and sent home with percocet. over saturday and sunday she became increasingly somnolent, sleeping excessively and refusing to eat. initially she would still drink water through a straw, but stopped doing that sunday. her husband called the for advice, and was told to call 911. she had not complained specifically of headaches and he did not notice photophobia or neck stiffness. she may have been urinating less, but did not complain of dysuria. ems arrived to find her supine on the couch complaining of back pain. in the osh ed her vs were t 99.6, hr 120, bp 132/68, 91% on ra. given ceftriaxone, flagyl, clindamycin, and vancomycin. episode of transient tachycardia to 120s that resolved with fluids. found to have new arf, a positive ua and leukocytosis to 20k with 14% bands. no imaging done there before she was transferred to the . . in the ed, initial vs were: t97.9 hr103 113/76 r30 98% on ra. she was very somnolent and confused speech when awoken. noted to have pustular and petichial rash over torso and lower extremities. difficult neurologic exam given cooperation. head ct normal. mri performed that was concerning for multiple diffuse epidural collections on a noncontrast scan limited somewhat by motion. spine service was consulted, who reviewed mri and felt no spine compression - no surgical intervention right now. lactate elevated. she received vanco, ceftriaxone, and was supposed to get ampicillin and acyclovir, which did not happen prior to transfer. did not lp given concern for epidural collections. blood cultures drawn (others pending at osh) and heme/onc consulted out of concern for ttp. on the floor, she is somnolent but arousable and does open her eyes. she grimaces on movement of any of her extremities but does not speak. will answer yes if asked if she has pain but does not speak. . review of systems: (+) per hpi, plus per husband a bad fall mechanical fall in her garden two months ago causing a facial hematoma. has had utis in the past but non recently. past medical history: - back pain/sciatica social history: principal with multiple flu contacts. denies etoh, drinking, illicit substances. son lives in , and is coming in tomorrow. family history: father lived to 96, mother lived to 86 then died after slow decline. physical exam: on admission: vitals: t: 97.7 bp: 107/52 p: 97 r: 26 o2: 93% on 4l nc general: arousable but closes eyes almost immediately. does not answer questions of orientation. heent: perrl, sclera anicteric, mmm, oropharynx with small pustules and signs of buccal trauma from biting. good dentition, not signs of abscesses. neck: neck stiff, but patient does not relax. no jvd. ? positive kernig's sign with resistance. patient resisting too much for brudzinski's sign. lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, grimaces on palpation of epigastrum and ruq, non-distended, bowel sounds present, no rebound tenderness, no organomegaly gu: foley in place. ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: diffuse tiny pustules over erythematous base, generally blanching, though some over hemorrhagic, non-blanching base. more concentrated over thighs, sparing face, palms and soles. . on discharge: general: answers questions appropriately. speaks slowly. fatigued. +anasarca heent: perrl, sclera anicteric neck: j in place lungs: tr crackles b/l bases cv: tachcardic, no murmurs, rubs, gallops abdomen: soft, nontender, +bs gu: foley in place. ext: warm, well perfused, severe pitting edema of b/l legs and rue skin: rash resolved neuro: cn2->12 grossly intact, able to move all fingers and toes. able to flex l arm at elbow against gravity, but not shoulder. not able to flex r arm against at arm or shoulder. cannot lift legs off bed. sensation grossly intact. pertinent results: on admission: . 136 98 133 ------------- 196 4.5 13 5.7 . ca: 7.2 mg: 3.1 p: 4.1 alt: 168 ap: 153 tbili: 3.6 alb: 2.1 ast: 141 ldh: 513 dbili: 3.1 lip: 11 . serum asa, etoh, acetmnphn, benzo, barb, tricyc negative . hapto: 267 . ......12.3 10.9 ------ 58 ......38.1 n:85 band:0 l:2 m:13 e:0 bas:0 . pt: 13.4 ptt: 27.8 inr: 1.1 fibrinogen: 837 . utox neg. . hiv neg . mri spine: multifocal small epidural collections as detailed above, predominantly in the thoracic spine. no significant cord compression is noted at any level. etiology for these collections could include infection or hematomas. appearance is not suggestive of neoplasm, although correlation with csf evaluation would be recommended.evaluation is limited due to lack of contrast. extensive degenerative changes in the lumbar spine with clumping of nerve roots at l5-s1. . ct head: no acute intracranial process. . ct abdomen/pelvis: no evidence of hydronephrosis or obstructive renal calculi. given noncontrast technique, pyelonephritis cannot be excluded. recommend clinical correlation. . echo: no vegetations or clinically-significant regurgitant valvular disease seen (reasonable-quality study). normal global and regional biventricular systolic function. mild pulmonary hypertension. in presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. . cxr: findings suggestive interval worsening of mild-to-moderate pulmonary edema; chronic interstitial lung disease may be present. . mri spine: overall no significant change compared to the previous study with the exam limited by motion. severe degenerative changes are identified with foraminal narrowing as above. the previously noted tiny epidural collection at l5-s1 level is not apparent but mild epidural enhancement is seen. no definite new collection is identified. . mri head: no significant abnormalities on mri of the brain with and without gadolinium. . ct pelvis: 1) no evidence of right hip infection or abscess. note that mri or radionuclide bone scan are more sensitive for the detection of early infection. 2) diffuse anasarca. . emg/ncs: complex, abnormal study. the electrophysiologic findings are consistent with a severe, subacute multilevel polyradiculopathy involving cervical and lumbosacral myotomes diffusely and would be consistent with either an inflammatory/infectious meningeal process. the abnormalities are most pronounced in the midcervical region. in addition, there is evidence for a superimposed neuromyopathy, as may be seen in acute quadriplegic myopathy of intensive care. c-spine non-trauma: five intraoperative radiographs of cervical spine with final images showing both anterior and posterior fusion extending from c4 through t1 posteriorly and c5 through t1 anteriorly. there is an interbody anterior graft at c5-6 and apparently c7 body has been partially replaced by a metallic device. . mri head: 1. no acute infarction or hemorrhage. 2. sinus disease as described above, the activity of which is to be determined clinically. 3. enhancing fluid within the left temporalis region suggestive of phlegmon. this enhancing collection previously demonstrated restricted diffusion. additional subcutaneous scalp fluid collections in the bilateral parietal regions may represent soft tissue edema; however, there is no evidence of enhancement to suggest abscess. . mri l spine: 1. new posterior epidural abscess extending from the level of l4-l5 to the level of s2 with phlegmonous extension into the paravertebral and paraspinous musculature. no evidence of enhancing intervertebral discs to suggest discitis. 2. advanced degenerative changes of the lumbar spine, unchanged since the previous examination. . mri t spine: 1. epidural abscesses are identified at the upper thoracic spine involving the levels of t1, t2, and t3, apparently slightly smaller since the prior examination, however, there is persistent enhancement surrounding the thecal sac and the spinal cord. 2. no evidence of abnormal signal within the thoracic spinal cord. 3. epidural abscess is again demonstrated at the level of t7/t8, causing anterior thecal sac deformity and also demonstrating pattern of enhancement. 4. heterogeneous signal is again redemonstrated in the bone marrow, likely consistent with a combination of osteomyelitis/discitis. 5. persistent bilateral pleural effusions. . xr l-spine: single intraoperative radiograph performed without a radiologist present. these demonstrate the lower lumbar spine. at the lumbosacral junction, instrumentation is demonstrated. background degenerative change is demonstrated in the remainder of the lumbar spine in the single intraoperative radiograph. for full details of surgery, please consult the operative report. . mri spine: impression: 1. persistent multiloculated small epidural abscess anterior to the thecal sac at the l5-s1 level measuring up to 2 cm in the si dimension and compressimg the thecal sac at this level. 2. markedly improved epidural abscesses at c5 through t1, t3-t4 and posteriorly at l4-l5. fluid collections in the resection bed within the cervical and lumbar spine may be postoperative, though infection cannot be excluded. 3. persistent multifocal abnormal bone marrow signal abnormality, consistent with extensive osteomyelitis. 4. large bilateral pleural effusions. . right upper extremity ultrasound: 1. fibrin sheath identified around picc line in the right basilic vein. the fibrin sheath does not extend beyond the basilic vein. 2. no deep venous thrombosis identified in right upper limb. . ultrasound: findings: grayscale and color doppler imaging of the common femoral, superficial femoral, and popliteal veins was performed bilaterally. normal compressibility, flow, waveform, and augmentation demonstrated. no intraluminal thrombus is identified. subcutaneous edema is noted bilaterally. impression: no lower extremity deep venous thrombosis bilaterally. brief hospital course: #. mssa infection (including epidural abscesses/vertebral osteo/meningitis/bacteremia/skin lesions/uti): pt found to have mssa from blood and also grew mssa from urine. vancomycin was started, then switched to nafcillin when the organism was identified. tte was performed and showed no vegetations. it is unknown what the portal of entry for the mssa was. the bacteremia, skin lesions and uti resolved with appropriate antibiotic therapy. ortho spine was consulted and recommended serial imaging to determine whether epidural abscesses were increasing in size or causing spinal cord compression. pt got mris approximately once a week and on the 3rd it was more clear that the patient would require surgery. she underwent neurosurgery and for epidural abscess drainage (and c7 corpectomy, c4-t1 fusion, t3-4 laminectomy). multiple abscesses present (~5, with 3 major ones), hardware place, cultures sent, debrided. upon repeat imaging post operatively, mri showed expanding t-spine epidural abscess, so she then underwent l spine decompression with debridement. per id, gentamycin was added to help with nafcillin penetration for a 5-day course, which was completed on . pt will continue on nafcillin for at least 8 weeks and will follow up with spine and id. her tentative stop date for nafcillin is , or it may be stopped on when she visits id. she has an appointment with spinal surgery on . she will need to have her staples removed on in rehab with log role , spine surgery. she is to have weekly draws faxed to the infectious disease physician, . . . #hospital acquired pneumonia: treated for hap with vancomycin and cefepime from through . her nafcillin was stopped during this treatment and was restarted on . . #. altered mental status: the patient was initially minimally responsive. this was thought to be secondary to meningitis as well as the severity of her infection. this resolved substantially with antibiotics. she did remain minimally delerious throughout her stay (generally oriented x3 with moments of confusion). mri head was normal. . # weakness: as pt's mental status improved and she became cooperative with neuro exam, it became clear that she had diffuse weakness with some focality (especially r arm) with sensation relatively intact. neurology was consulted who felt that some of the weakness could be cord inflammation and so pt recieved pulsed steroids early in her admission without significant effect. pt underwent emg which showed a mixed picture (see emg report for full details). pt did undergo decompression on and but strength remained similar. . #. gi bleed: on pt developed melanotic stools and a hematocrit drop from 24 to 20. iv ppi was continued and she recieved 1u of prbcs and had an egd which showed severe ulcerations in stomach and duodenum most consistent with nsaid use (pt did use ibuprofen at home). per pt she had had a normal colonoscopy at 4 yrs ago and this was not repeated as an inpt. pt also reports h/o duodenal ulcers in the . an h pylori was sent and was positive. treatment of h pylori was deferred in setting of nafcillin therapy and severe infection. pt was continued on ppi, eventually transitioned to po. pt will need 2 week course of amoxicillin and clarithromycin after her nafcillin treatment is complete (nafcillin does not cover h pylori.) she should continue lansoprazole until her visit with the gastroenterologist in . . #. persistent sinus tachycardia: pt maintained hr of ~100 throughout her admission (~1 month). this was felt to most likely be related to her severe underlying infection and recurrent low grade fevers. intravascular volume depletion was also a likely contributor given pt's low albumin and anasarca and clinical appearance of being dry (dry mouth, low jvp). pe was considered, however, pt was on dvt ppx throughout admission and ekg did not have any changes. further, pt's oxygen requirement was minimal to none and ultimately it was decided that pe was highly unlikely. also given her prolonged stay may be a pe, though this is less likely. . #. edema: patient was noted to have anasarca and an albumin of 1.9. pt was not diuresed aggressively as she appeared intravascularly depleted and had minimal oxygen requirement. her edema improved upon discharge. . #. anemia: pt remained anemic throughout her stay. perhaps she has had ulcers for some time contributing to her anemia. her reticulocyte count was 6.7 arguing against marrow suppression as the etiology, however, iron studies were consistent with anemia of chronic disease. the transfusion goal was set at 22. she recieved 2u of prbcs throughout her stay. . #. pain: patient had severe back pain throughout her admission that was ultimately treated with a fentanyl patch with small boluses of iv morphine for breakthrough pain. a kanair bed was also found to help with her pain. . #. rash: on admission pt had 2 rashes. she had diffuse small pustules which grew mssa and resolved c antibiotics. she also had, on the left back, a 4 x 3cm erythematous plaque with a central brown / black, rough, necrotic area which was biopsied by dermatology and showed "focal necrotizing vasculitis in mid-dermis with focal thrombosis, and ischemic necrosis of epidermis and appendages" which dermatology felt was consistent with a reactive process, rather than representing a primary vasculitis, given the clinical scenerio. . #. acute renal failure: pt had on admission, which resolved c ivf. . #. elevated transaminases: pt had elevated lfts on admission, most likely from poor perfusion in the setting of dehydration or billiary sludging in the setting of sirs. ruq ultrasound unremarkable. this was trended and resolved. . #. thrombocytopenia: in combination with direct bilirubinemia was concerning for consumptive process like ttp or dic on admission, however no chistocytes on smear. most likely due to poor production in the setting of infection and resolved during admission. . #. nutrition: she failed speech and swallow on . a percutaneous gastrojejunostomy tube was placed on and tube feeds continued. . # electrolyte abnormalities: patient had persistent hypokalemia and hypophosphatemia. standing electrolyte orders were instilled and should be continued in rehab until levels normalize. also, a chem-10 should be checked every other day while taking these medications. #. access: patient has a picc placed in the right arm on . #. code: full code ------------- to do - treat for h pylori after treatment for mssa complete - take out staples on in rehab - continue age appropriate cancer screening - continue pain management without nsaids medications on admission: tylenol and ibuprofen generally for back pain. this past week tamiflu, vicodin and percocet. discharge medications: 1. oxycodone 5 mg/5 ml solution : one (1) po q6h (every 6 hours) as needed for pain. 2. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day). 3. heparin, porcine (pf) 10 unit/ml syringe : one (1) ml intravenous prn (as needed) as needed for line flush. 4. lovenox 40 mg/0.4 ml syringe : one (1) subcutaneous once a day: to be discontinued when able to move around q8h. . 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : adhesive patch, medicateds topical daily (daily): 12 hours on, 12 hours off . 6. insulin regular human 100 unit/ml solution : per sliding scale injection asdir (as directed) as needed for hyperglycemia. 7. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for fever or pain. 8. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constip. 9. polyethylene glycol 3350 17 gram/dose powder : one (1) po daily (daily) as needed for constipation. 10. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day): hold for loose stools. 11. morphine 2 mg/ml syringe : one (1) injection q4h (every 4 hours) as needed for pain: hold for sedation, rr<12. 12. fentanyl 50 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 13. lisinopril 10 mg tablet : one (1) tablet po daily (daily). 14. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 15. outpatient work pt, ptt, inr, chem-7, lfts, cbc/diff every monday faxed to infectious disease r.ns. at ( 16. nafcillin in d2.4w 2 gram/100 ml piggyback : two (2) grams intravenous q4h (every 4 hours): start date: last dose should be . 17. outpatient work please check chem-10 every other day until electrolytes are normalized. 18. potassium chloride 20 meq packet : one (1) packet po tid (3 times a day): hold for k > 4. 19. phos-nak 280-160-250 mg powder in packet : two (2) po once a day: hold for phos > 4. discharge disposition: extended care facility: - discharge diagnosis: mssa epidural abscesses, mssa meningitis and vertebral osteomyelitis and discitis, mssa uti, mssa bacteremia, mssa diffuse skin pustules, profound weakness. dysphagia. anasarca. duodenal and gastric ulcers complicated by bleeding. discharge condition: vital signs stable. very weak legs and r arm more swollen than l arm, but very diffuse weakness. anasarca. intermittently confused. discharge instructions: you were admitted with a bacterial infection of your spinal fluid and the bones of your spine as well as your urine and blood and skin. you were treated with antibiotics and the orthopedic surgeons did two surgeries to take out the abscesses. you also had a lot of weakness, for which we had neurology see you. they felt that your weakness was due to a combination of factors including the infection around your spine and also some muscle weakness from being so weak. you worked extensively with physical therapy and will continue to do so at rehab. . you were having difficulty swallowing as well, thought secondary to pharyngeal inflammation from your cervical spine surgery and muscle weakness from prolonged hospitalization. you therefore had a gastrojejunostomy tube placed to receive nutrition. . you will need to wear the cervical collar until you meet with the spine surgeons on . you have staples on your back. these will need to be removed . we spoke with the spine surgeons and they stated your facility can remove these under log role precautions. . you will need to continue nafcillin until at least , unless the infectious disease specialists tell you otherwise at your appointment on . followup instructions: please help ms go to the following appointments: provider: (infectious disease), md. phone date: 10:30am provider: (infectious disease), md phone: date/time: 9:30a provider: (gastroenterology), md phone: date/time: 3:00p provider: (spine surgery) phone: date/time: 12:20 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung other endoscopy of small intestine diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances biopsy of bone marrow laryngoscopy and other tracheoscopy other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal excision of intervertebral disc excision of intervertebral disc percutaneous [endoscopic] gastrojejunostomy open biopsy of soft tissue closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue biopsy of bone, other bones biopsy of bone, other bones other cervical fusion of the posterior column, posterior technique other repair and plastic operations on spinal cord structures insertion or replacement of skull tongs or halo traction device plastic operation on pharynx insertion of interbody spinal fusion device fusion or refusion of 4-8 vertebrae diagnoses: acidosis thrombocytopenia, unspecified anemia of other chronic disease acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified acute posthemorrhagic anemia candidiasis of mouth hypopotassemia other nervous system complications diaphragmatic hernia without mention of obstruction or gangrene other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site disorders of phosphorus metabolism chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction nausea alone chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction hyperosmolality and/or hypernatremia intraspinal abscess acute osteomyelitis, other specified sites helicobacter pylori [h. pylori] other and unspecified disc disorder, thoracic region volume depletion, unspecified candidiasis of vulva and vagina polyarteritis nodosa unspecified analgesic and antipyretic causing adverse effects in therapeutic use cervical spondylosis with myelopathy nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] edema malnutrition of moderate degree aspiration of fluid as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure dysphagia, unspecified staphylococcal meningitis proteinuria other symptoms involving digestive system 

Answer: The patient is high likely exposed to