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 / cephalosporins / codeine attending: chief complaint: group b strep endocarditis with od endophthalmitis major surgical or invasive procedure: tee picc line placement egd history of present illness: this is a 62yo female with history of autoimmune hepatitis on chronic immunosuppression, liver cirrhosis, diabetes, copd, chronic leg swelling from previous fracture, on imuran and prednisone, transferred from osh with strep b bacteremia and endopthalmitis. the patient was initially admitted to osh on for diarreha, nausea, and vomiting, with fever of 102 on the day of admission. she was initially felt to have an acute gastroenteritis, mild chf, and lle cellulitis. on admission she was started on iv vanc for presumed lle cellulitis, and her other meds (including imuran and prednisone) were held. she developed acute loss of vision in her r eye on the night of admission, and mri/mra was obtained. mri showed multiple punctate bilateral embolism c/w septic emboli. she was started on heparin. neurology recommended echo and mra of the aortic arch, concluding her symptoms were c/w embolic stroke. her gastroenterologist, dr. , recommended continuing the pts imuran and prednisone. she was also started on stress dose solu-cortef for unclear reasons (not clear if pt was hypotensive). on she was started on iv gent in addition to her iv vanc. prior to transfer she was seen by opthamology who felt her sxs were consistent with endopthalmitis and needs urgent eval for vitreous tap and possible vitrectomy. of note, the pt is growing 4/4 bottles from with strep agalactiae group b. cxr on was c/w mild chf. esr on was 75. urine cx on is growing strep agalactiea. echo on was suspicious for mitral valve vegetation. . past medical history: a-utoimmune hepatitis with liver cirrhosis and splenomegaly--on imuran and prednisone -grade i esophageal varices -anemia in setting of imuran -copd -depression -osteopenia -chronic sinusitus -endometrial metaplasia -l ankle arthritis social history: employed as conservation . husband. two children. non smoker family history: non contributory physical exam: pe: 96.9, 130/62, 71, 18, 94%ra gen: ill appearing female laying in bed with eyes closed. heent: right eye with cloudy purulence coating , pupil. scleral injection. no proptosis. able to visualize light through right eye, no movement. no papilledema left eye. vision intact on left. jvp to ear lobe. cv: iii/vi sem lusb radiating to carotids. holosystolic murmur to apex. lungs: sparse crackles at bases bilaterally ab: distended, non tender, + bs. liver not palpable. extrem: 2+ edema on right, 3+ on left. erythema over posterior aspect of calf, anteriorly to knee. non tender to palpation. chronic venous stasis changes. 2+ dp right, 1+left given edema difficult to palpate. neuro: alert and oriented x 3. eomi. cranial nerves not skin- no lesions on palms or soles, echymoses throughout body. pertinent results: 09:21pm glucose-175* urea n-28* creat-1.0 sodium-138 potassium-3.7 chloride-105 total co2-25 anion gap-12 09:21pm estgfr-using this 09:21pm alt(sgpt)-20 ast(sgot)-22 alk phos-79 tot bili-3.7* 09:21pm calcium-8.0* phosphate-3.1 magnesium-2.3 09:21pm wbc-15.9*# rbc-3.41* hgb-12.5 hct-36.3 mcv-106* mch-36.8* mchc-34.5 rdw-16.5* 09:21pm neuts-86.9* lymphs-5.9* monos-6.0 eos-0.1 basos-1.1 09:21pm anisocyt-1+ poikilocy-1+ macrocyt-3+ 09:21pm plt count-130*# 09:21pm pt-18.9* ptt-35.4* inr(pt)-1.8* blood work complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 07:00am 13.8* 2.58* 9.6* 28.0* 109* 37.4* 34.5 21.7* 59* source: line-picc inr 1.5 renal & glucose glucose urean creat na k cl hco3 angap 07:00am 139* 34* 0.7 128* 4.2 94* 31 7* enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 07:00am 34 41* 79 6.5* . ct head impression: no evidence of acute intracranial hemorrhage. multiple hypodensities could be consistent with history of septic emboli. however, for specific evaluation, a contrast-enhanced ct of the brain or mri is recommended. . echo conclusions: no thrombus is seen in the left atrial appendage. the interatrial septum is aneurysmal, but no atrial septal defect or patent foramen ovale is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular systolic function is normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. there is a large (1.6 x 1.5 cm) vegetation on the posterior mitral leaflet, with leaflet perforation. an associated jet of severe (4+) mitral regurgitation is seen. the anterior mitral leaflet is normal in appearance, and there is no associated mitral annular abscess. no vegetation/mass is seen on the pulmonic valve and tricuspid valve. impression: mitral valve endocarditis with posterior leaflet perforation. severe mitral regurgitation. . pelvis ultrasound this is a technically difficult examination. the transabdominal study is very limited due to the patient's body habitus. endovaginal examination was also technically difficult. the uterus measures 4 cm in transverse x 4.7 cm in ap x 6.5 cm in sagittal dimensions. the endometrial stripe measures 5 mm in maximum dimension. multiple heterogenous areas are identified within the uterus in the mid body which may represent fibroids. the largest of these measures less than 2 cm. the ovaries are not visualized. impression: technically difficult abdominal and transvaginal examinations in patient with normal endometrial stripe thickness and heterogenous appearance of uterus which may represent fibroids. ovaries not imaged. . doppler liver color & pulsed doppler son liver: normal flow and waveforms are demonstrated within the hepatic arteries. no portal venous flow is identified within the main portal vein and the main portal vein is not well delineated. impression: 1) heterogeneous echotexture of the liver consistent with cirrhosis. no focal mass lesion identified. 2) the portal vein is not well delineated on this study. no color flow or doppler pulse is present within the expected region of the portal vein. chronic portal vein thrombus cannot be excluded. 3) cholelithiasis without evidence of cholecystitis. . repeat echo no significant changes from prior. . brief hospital course: this is a 62 yo pt with autoimmune hepatitis on chronic immunosuppression transferred from osh, with group b strep bacteremia, septic brain emboli, endopthalmitis, endocarditis with large mitral valve vegetation and small perforation. # endocarditis/bacteremia: the patient was initially on vancomycin and gentamycin when transferred, and placed on the sepsis protocol. as per id, gentamycin was discontinued and then was switched to penicillin 3 million units q 4 hours iv after desensitization in the micu without adverse reaction. pt was afebrile while in house, with no growth from blood cultures in house. vitreous fluid grew group b strep sensitive to vancomycin and penicillin. id followed the patient and she must remain on antibiotics for a minimum of six weeks. on id follow up on the , they will determine the total treatment length. a picc line was placed on . . # mitral valve damage: given bacteremia and probable septic emboli, as well as likely mitral vegetation on outside hospital tte, tee was performed . this revealed large mitral valve vegetation with perforation and severe mitral regurgitation. cardiac surgery was immediately consulted. they followed the patient and determined she was not a surgery candidate given her multiple risk factors, including her childs b/c classification. the patient was started on lasix 20 mg po daily, and a low dose of lisinopril. her beta blocker was increased, and she tolerated these changes well until an episode of low bp(see below). prior to discharge, her nadolol was again reduced to 10 mg and tapered off due to decreased low pressure in the setting of steroid taper. she developed hypotension 70s/doppler on , which did not respond appropriately to 1.5 l fluid bolus plus one unit prbcs. she was put back on stress dose steroids, all bp meds were d/c and new blood cultures were sent, with no growth. the next day, a new echo was ordered out of concern for cardiogenic shock. the results were similar to the previous one. she never became febrile or tachycardic. on , bp was 100s/doppler and the patient continued to be asymptomatic. she compalined of intermittent atypical chest pain, and several ekg revealed no ischemic changes. she needs to be on afterload reduction ideally, consisting of bb, ace-i and lasix, however due to her blood pressure running in the 100's systolic without any symptoms, these medications were stopped and should slowly be added back as blood pressure tolerates. patient is clinically hypervolemic with le edema and jvd, however no evidence of pulmonary fluid overload on exam. . # embolic stroke: mri/mra outside hospital with evidence of punctate lesions likely septic emboli. pt was on heparin at outside hospital, but given risk of hemorrhagic bleed into emboli, it was discontinued upon presentation to the . neurology followed the patient in house. she was disoriented at times but this was more consistent with hepatic encephalopathy and depression. she did not develop any neuro deficits. ct head repeated with no evidence of acute bleed. . #endophtalmitis: the patient presented with hypopyon and complete vision loss. she underwent tap and aspiration, but not vitrectomy, liquid growing strep b, and had antibiotics injected directly into the chamber: vancomycin and cefepime. ophto followed closely and they deem the r eye not salvageable. evisceration versus enucleation was planned, however the patient wished to wait. in the meantime, she was continued on eye drops recommended by ophto (see medication list). she must protect her remaining eye at all times. she has been arranged for follow up with ophto. . #hyperkalemia and hyponatremia- no evidence of adrenal failure. with hyponatremia and hyperkalemia, there was concern for adrenal insufficiency, though patient was on stress dose steroids, which were subsequently tapered to 10 mg daily iv, then started po on 80 mg, tapered down to 20 mg po daily, final goal 5 mg every other day. pharmacy was consulted about penicillin with ~30 meq daily potassium, but they did not feel that this could cause persistent hyperkalemia. the patient was previously on k sparing diuretic spironolactone which was held. the patient required lyte checks for a few days and several doses of kayexelate. the hyperkalemia resolved 8 days prior to discharge, also in the setting of increased insulin. hyponatremia persists, and is consistent with adh derangements with concentrated urine osmolality. the patient was placed on free water restriction 1.5 liter daily. . #thrombocytopenia- platelets decreased during admission, but remained above 50 except for a value in the 40s on . low platelets are in the setting of cirrhosis with compromised synthetic function (albumin 1.5). she received vitamin k sq x 3 doses. hit was positive, but serotonin release antibody was negative, therefore the patient was continued on sq heparin with no evidence of decreased platelet count or thrombosis. small amount of vaginal bleeding during admission, which resolved. . #cirrhosis: egd demonstarted grade i varices. the hepatology service followed the patient. imuran was held. nadolol was re-started at 10 , then increased to 20 . the bb was subsequently decreased again to 10 mg in the setting of low blood pressures. aldactone was held with the development of hyperkalemia. the patient developed hepatic encephalopathy with asterixis and lactulose was begun and titrated to 3 bm daily, with the patient's mental status improving. the patient developed worsening unconjugated bilirubinemia with some evidence of hemolysis. bilirubin then trended down (although it remains elevated). transaminases remained normal with a mild elevation the last few days. hepatology started rifaximin on . per hepatology, imuran can be restarted if lfts double. taper of prednisone can continue while watching her lfts. she should continue on 20 mg prednisone daily for and and then be decreased to 10 mg daily to be continued indefinitely. . #hemodynamics: the patient blood pressure became low on and . on , she triggered for bp 78/doppler. she was clammy on exam but not lightheaded or diaphoretic. that same day, her hct<25 with no significant bleeding (she had persistent hematuria throughout admission, insufficient to explain her hct drop). she was treated with 1500 cc ns and transfused one unit, without adequate response. she was started on stress dose hydrocortisone. after transfusion, the hct was appropriately 2 points higher. blood cultures were sent, which were negative. the next day, an echo showed no changes from prior. bp was 100s/doppler and an ekg was obtained as described above, with no ischemic changes. the patient's blood pressure stabilized and she was again placed on steroid taper 2 days later. discharge bp was 100/50, which is consistent with patient's baseline bp. . #hyperglycemia: initially the patient's sugars were 200-300s. lantus dose was increased to 32 units, then 34 and 36, and humalog as well as sliding scale was successively tightened. at discharge, the finger sticks were significantly improved, and the lantus dose is again decreased in setting of steroid taper. . #depression: initially, all psychotropic medications were held due to the patient's poor mentation in the setting of bacteremia and possibly hepatic encephalopathy. the patient's sensorium cleared significantly with treatment, however her mood became increasingly depressed. the patient endorsed feelings of hopelesness, helplessness, and deep depression. celexa was restarted on . . #vaginal bleeding: the patient developed mild vaginal bleeding with stable crit. she had had a normal gyn exam and pap 4 months prior to admission. gyn was consulted and examination revealed dark blood at the cervical os. they recommend that the patient have an endometrial biopsy as an outpatient. . #funguria: two successive urine cultures revealed yeast. a decision was made to institute a short course of fluconazole (last day ) given the patient's immunosppression. an attempt was made to d/c foley, but the patient became unable to void, and the foley was reinstituted. a spontaneous voiding trial on 5/ 5/ 07 again resulted in the patient being unable to void, therefore the foley remains in place at discharge. the patient had at all times a normal neuro exam and specifically, she did not have saddle anesthesia. . #adl: pt and ot evaluated the patient and the consensus is that she is significantly below baseline and has excellent rehab potential. the patient is severely deconditioned and has difficulty ambulating at discharge. . #fen: diabetic, cardiac diet . #ppx: ssi while on steroids, ppi, heparin sq. . #code: full . # husband at . #dispo- to rehab. medications on admission: -imuran 75 mg daily -aldactone 100 mg daily -lasix 40 mg daily -prednisone 20 mg daily -solu-cortef 100 mg iv bid -vanc 1 g iv bid -garamycin 80 mg iv q 8hr since -heparin gtt discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours) as needed. 2. ciprofloxacin 0.3 % drops sig: one (1) drop ophthalmic q3h (every 3 hours): right eye. 3. brimonidine 0.15 % drops sig: one (1) drop ophthalmic (2 times a day): right eye. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 7. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 8. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed. 9. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. penicillin g potassium 5,000,000 unit recon soln sig: one (1) recon soln injection q4h (every 4 hours). 12. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic q3h (every 3 hours): right eye. 13. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed. 14. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic (2 times a day): right eye. 15. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 16. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 17. lactulose 10 g/15 ml syrup sig: forty five (45) ml po tid (3 times a day). 18. rifaximin 200 mg tablet sig: one (1) tablet po tid (3 times a day). 19. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 2 days: please continue for and . . 20. prednisone 10 mg tablet sig: one (1) tablet po once a day: please start on and continue indefinitely. . 21. insulin please continue glargine and humalog per sliding scale insulin sheet attached to discharge paperwork. discharge disposition: extended care facility: - discharge diagnosis: primary: endocarditis with mitral valve rupture endophtalmitis with irreversible loss of vision od septic emboli brain autoimmune hepatitis with cirrhosis and bilirubinemia secondary: diabetes mellitus anemia thrombocytopenia funguria vaginal bleeding urinary retention hepatic encephalopathy discharge condition: fair to good. discharge instructions: you were admitted with an infection in your heart (endocarditis), which has damaged one of your heart valves, the mitral valve. in addition, your right eye was severely infected with endophtalmitis and you also had some septic emboli to your brain. other problems with which you presented were uncontrolled blood sugars, anemia (low blood), and yeast infection to your urine. you were desensitized to penicillin and have been receiving penicillin intravenously. this antibiotic needs to be continued for at least 6 weeks, and can be administered through the picc line that was placed in your right arm. you need to follow the recommendations of your infectious disease doctor (with whom you have an appointment) as to the exact number of days you must take antibiotics. please continue the antibiotics until you see the id physician. medical consults were ordered while you were in the hospital: - the liver service recommended you stop taking imuran. your steroid dose was also slowly reduced to 20 mg daily, which is your current dose and will be further tapered to 10 mg daily. - the eye doctors recommend surgery on your right eye, and you need to follow up with them. you must protect your left eye at all times. - you were also seen by a gynecologist for vaginal bleeding, and you need to arrange for an endometrial biopsy as an outpatient. - the gi doctors examined your , stomach and duodenum and found enlarged veins. you were started on a medication to control your fluid status, lasix, once a day. you were also started on a new blood pressure medication, lisinopril. your nadolol dose was increased to help your heart. however due to lower blood pressures, these medications were stopped and can be restarted slowly. followup instructions: dr (eye, center) , 2:30 pm with your gynecologist as soon as feasible. with provider (infectious disease): , md phone: date/time: 9:00 with provider: , md phone: date/time: 10:45 md, procedure: venous catheterization, not elsewhere classified other endoscopy of small intestine diagnostic ultrasound of heart therapeutic evacuation of anterior chamber diagnoses: thrombocytopenia, unspecified anemia, unspecified mitral valve disorders congestive heart failure, unspecified cirrhosis of liver without mention of alcohol diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia candidiasis of other urogenital sites chronic airway obstruction, not elsewhere classified depressive disorder, not elsewhere classified sepsis hypopotassemia cellulitis and abscess of leg, except foot retention of urine, unspecified other chronic hepatitis cerebral embolism with cerebral infarction hepatic encephalopathy streptococcal septicemia other endophthalmitis disorder of bone and cartilage, unspecified venous (peripheral) insufficiency, unspecified endocarditis, valve unspecified, unspecified cause esophageal varices without mention of bleeding osteoarthrosis, localized, not specified whether primary or secondary, ankle and foot 

Answer: The patient is high likely exposed to