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 attending: chief complaint: hypotension 2/2 blood loss from large leg wound major surgical or invasive procedure: dialysis and cvvh tunneled catheter placement temporary hd line removal history of present illness: 62f h/o esrd, on dialysis, presented from hypotensive to 56/41 and bleeding from a r lateral thigh wound. pt reports a operation during which ivc filter was removed. reports, pt had infected ivc filter removed but no mention of a lateral thigh surgery. on the discharge summary, it does state to continue "duoderm to her sacral and right thigh decubiti." she had been initiated on coumadin therapy for dvt (unclear when this was diagnosed). the d/c summary did comment that she was having guaiac + stools prior to starting coumadin. she was being seen by visiting nurses for the dressing changes to the decubiti. pt reports that the wound had been bleeding over the past 5 days but started bleeding a lot today. patient's initial hct here is 20 and inr 7.7. in the ed, t 96.2, bp 56/41, hr 71, rr 28, sao2 93% on ra. pressure dressing applied. vascular surgery and transplant surgery saw her in the ed. pt received 4units prbc and 1unit ffp, as well as vitk 10mg sc x1. pt also received vanco x 1, ceftazidime x1 and levofloxacin x1. pt also received calcium gluconate 1g iv x1. micu course was notable for intermittent asymptomatic hypotension. she has received 7 prbc and 1 unit of ffp for the hospital course to date. the last of which was on . as her admission weight was markedly elevated above her estimated dry weight, she aggresively ultra-filtrated with cvvh for 3 days. a set of blood cultures from arrival to the ed were positive (result available day 2 days after admission) for viridans strept and she has remained on vanc/aztreonam. renal team recommeded obtaining doing venogram to r/o central stenosis as the patient had a recent history of low flows via her hd catheters. wound care team made recommendations regarding her numerous pressure ulcers. midodrine was added to help with her baseline arterial dilation from her esrd. her los fluid balance in the micu was -15.8l. upon arrival to the medical floor, she is breathing comfortably and has only some mild itching around the tape over the leg wound. ros: no chest pain, no sob, no abd pain, no diarrhea. still constipated. past medical history: # esrd on hd t, th, sat # dm # chf # hypercholesterolemia # ble dvts, on warfarin # osa # oa # multiple line infections --: providencia, finished 4wk course of aztreonam --: staph coag positive, sensitive to both vancomycin and gentamicin # h/o c. diff # gerd # depression # morbid obesity past surgical history: # l forearm radial-basilic av graft () # multiple lines in l upper arm with av graft # 1/07 l femoral permacath placed # l upper arm thrombectomy, revision, then removal of lue av graft () # permacath and ivc filter removed social history: has lived at , ma, since family history: nc physical exam: vs: temp: 97.1, bp: 83/32, hr: 70, rr: 15-17, o2sat 100 on 2l nc gen: pleasant, morbidly obese, comfortable, nad, conversing, alert and oriented. heent: perrl, eomi, anicteric, mmm, op without lesions, no teeth neck: very obese neck and exam difficult but no obvious supraclavicular or cervical lymphadenopathy, jvd resp: cta b/l with good air movement throughout cv: distant rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no hepatosplenomegaly, large hard subcutaneous mass on rlq ext: no c/c/e, warm, good pulses. ?fungal infection at bilateral soles skin: patient with right ?surgical wound, pressure ulcer on folds of abdomen. neuro: aaox3. cn ii-xii intact. 5/5 strength throughout upper body, 4/5 strength in le. no sensory deficits to light touch appreciated. rectal: stool guiaic positive here pertinent results: 09:35pm blood wbc-9.4 rbc-1.87*# hgb-5.9*# hct-19.9*# mcv-106* mch-31.7 mchc-29.8* rdw-18.5* plt ct-477* 09:35pm blood neuts-75* bands-1 lymphs-16* monos-3 eos-3 baso-0 atyps-0 metas-1* myelos-1* nrbc-1* 09:35pm blood hypochr-occasional anisocy-2+ poiklo-2+ macrocy-1+ microcy-1+ polychr-1+ spheroc-occasional ovalocy-occasional burr-1+ acantho-1+ 09:35pm blood ret man-2.3* 09:35pm blood pt-64.0* ptt-47.5* inr(pt)-7.7* 09:35pm blood glucose-122* urean-19 creat-3.8*# na-137 k-4.0 cl-107 hco3-16* angap-18 09:35pm blood alt-19 ast-32 ld(ldh)-223 ck(cpk)-29 alkphos-173* totbili-0.2 09:35pm blood albumin-1.6* calcium-6.4* phos-5.4* mg-2.4 iron-58 09:35pm blood caltibc-72* vitb12-519 folate-9.6 ferritn-995* trf-55* 09:45pm blood lactate-4.5* 02:43am blood lactate-1.8 10:38pm blood wbc-12.2* rbc-3.21* hgb-10.1* hct-31.9* mcv-100* mch-31.6 mchc-31.7 rdw-20.2* plt ct-582* 10:38pm blood glucose-116* urean-18 creat-2.5* na-135 k-4.9 cl-102 hco3-23 angap-15 03:48am blood alt-19 ast-20 ld(ldh)-210 alkphos-240* totbili-0.3 . ekg: rate of 70, nsr, nl axis, nl intervals, no significant st changes. unchanged from prior. . imaging: . cxr: costophrenic angle excluded from the radiograph. mild left basilar opacity, likely atelectasis. no evidence for chf or airspace consolidation. . bilateral lower extremity veins: no evidence of deep vein thrombosis in either leg. venogram / svc gram: wideliy patent central veins including the subclavain veins and brachiocephalic veins bilaterally. small collateral veins were noted at the level of the proximal right subclavain vein. tunneled line placement: successful exchange of indwelling temporary hemodialysis catheter with a 15.5 french tunneled hemodialysis catheter with 23 cm tip-to-cuff length and tip positioned at the right atrium. the catheter is ready for use. patent central veins with small collateral veins at the level of the proximal right subclavain vein. : no valvular vegetations seen. moderate pulmonary hypertension is suggested. compared to the prior study dated , no change. : no mass/thrombus is seen in the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch and descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. impression: no echocardiographic evidence of endocarditis. normal biventricular systolic function. mild to moderate mitral regurgitation. ct abd/pelvis w/ contrast: abdomen: the lung bases are clear, with minimal dependent atelectasis noted. mitral annular calcifications are present. the liver, spleen, pancreas, and adrenal glands are within normal limits. medullary pyramid density likely represents a small amount of excreted contrast as this has not been present on prior studies. the gallbladder appears somewhat distended. however, no stones are seen and there is no evidence of biliary ductal dilatation. the size is similar to the ct of . there is no free fluid, bowel dilatation, or pathologic lymph node enlargement within the abdomen or pelvis. vascular calcifications are moderate. pelvis: an enlarged uterus with multiple fibroids persists. the rectum and sigmoid appear normal. the bladder is collapsed. there is diffuse muscle atrophy. osseous structures: there are no suspicious lytic or blastic lesions. facet joint degenerative changes are moderate. impressions: 1. no ct evidence of acute process within the abdomen or pelvis. although the gallbladder is slightly distended, it is similar in size when compared to the study of . discharge labs: inr 2.0 chem 10: na 130 k 4.2 cl 93 bicarb 25 bun 32 cr 5.1 glucose 92 ca 9.9 phos 5.3 mg 2.2 cbc: hct 32.1 wbc 9.5 plt 529 culture data: blood culture : blood culture, routine (preliminary): viridans streptococci. of three colonial morphologies. isolated from one set only. sensitivity testing per dr., pager . being isolated for sensitivities. anaerobic bottle gram stain (final ): reported by phone to @ 3:15pm . gram positive cocci in chains. blood cultures: negative on , pending upon discharge on , (no growth to date) rectal swab + for vre inferring colonization brief hospital course: hypotension: patient initially presented as hypotensive and was transferred to the icu. she was very anemic due to her blood loss to a hct of 19.9 on (in her hct was 41.4). she was transfused 7 units and volume resuscitated. it was thought her hypotension was due directly to blood loss from right leg wounds associated with a lift injury, upon presentation her inr was 7.7 (on coumadin for dvt). she was hemodynamically stable although very volume overloaded and transferred to the floor. esrd: as above, transferred to floor very volume overloaded and she was ultrafiltrated aggressively and dialyzed intermittently. she should resume a saturday, tuesday, thursday schedule for dialysis. her dialysis line was removed as it was pulled out about 10cm and a new tunneled l ij was placed. this was done under interventional radiology and at this time she underwent a venogram and svc gram to evaluate for clot or stenosis and she had no venous clots or svc stenosis. on she had lower extremity dopplers without any dvt seen. she will have dialysis tues / thurs / saturday at the in . dvt: she was on coumadin for dvt in the past, her inr was supratherapeutic on admission, she was on 6mg po daily. this was held in the setting of her bleed. as above no dvt on current venogram / ultrasounds, but given high risk (recent dvt, immobilization and esrd on dialysis) the patient should be anticoagulated, she was started on coumadin on with 5mg daily, her inr should be checked q2-3 days in her skilled nursing facility / rehab and her coumadin should be titrated to a goal inr of . bacteremia: the patient was found to have three different morphologies of strep viridans on a blood culture drawn for hypotension (even though she had a obvious other cause of blood loss). repeats were negative, no new murmur or endocarditis. no localizing source of infection, no underlying valvular disease. tte and tee echos were performed which effectively ruled out endocarditis and a ct of her abdomen and pelvis with contrast ruled out any infection / abscess in these regions. she should continue a 2 week course of vancomycin dosed with hemodialysis as day # 1 being . she should continue until for "simple" bacteremia. per micro lab this is likely a contaminant but given the patients high risk for microbial infection given diabetes, vascular access and skin breakdown issues our infectious disease specialists felt it prudent to treat for a 2 week course with vancomycin. sensitivies on the strep viridans were pending upon discharge, although it would be very rare for this organism to be vancomycin resistant. vomiting: patient is without dentures and occasionally vomits after eating, she does feel like food is "getting stuck" but does feel much better with a mechanical soft diet. she should be set up for dentures while at her nursing home through a dentist. until that time she should remain on a mechanical soft diet. if her dysphagia / vomiting persists after she has teeth and is on a normal diet she should likely have a barium swallow and motility study to evaluate this process and possibly and upper endoscopy. right leg wounds: patient was seen by wound care nurses as an inpatient and wound care recommendations were made. please continue local wound care, no active infection. please continue medications on medication list for wound care. dm - nph 20units qam + plus insulin sliding scale (beginning with 2 units of humalog for a blood glucose of 150-200). blood glucose was very well controlled on this regimen. sleep apnea: patient is intolerant of cpap mask and frequently desats overnight if not wearing supplement o2. she did well on 2 liters nasal cannula overnight. communication: hcp is oldest daughter , currently in without phone number. other daughters , , and , . medications on admission: medications confirmed with : warfarin 6mg qhs metoprolol 25mg mvi tylenol paroxetine (paxil) 10mg daily oxazepam (serax) 10mg qhs prn insomnia lactulose prn constipation nph 20units qam, riss senna 8.6mg qhs colace 100mg po bid calcium carbonate 500mg qid prn indigestion ============================================ additional medications from omr note: dulcolax 10mg daily renagel 1600mg tid furosemide 40mg nephrocaps ferrous sulfate 325mg daily metoprolol 25mg qtuthsa with dialysis discharge medications: 1. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 2. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. paroxetine hcl 10 mg tablet sig: one (1) tablet po daily (daily). 4. insulin nph human recomb 100 unit/ml suspension sig: as directed subcutaneous once a day: 20 units of nph qam. 5. insulin regular human 100 unit/ml solution sig: as directed injection four times a day: per sliding scale. 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. papain-urea 830,000-10 unit/g-% ointment sig: one (1) appl topical daily (daily). 11. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 12. morphine 15 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 13. diphenhydramine hcl 25 mg capsule sig: capsules po q6h (every 6 hours) as needed for itching. 14. papain-urea 830,000-10 unit/g-% ointment sig: one (1) appl topical daily (daily). 15. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): continue until inr is therapeutic (inr ). 16. warfarin 5 mg tablet sig: one (1) tablet po daily16 (once daily at 16) for 3 days: please monitor inr every 2 or 3 days and adjust coumadin dose accordingly. 17. vancomycin in dextrose 1 gram/200 ml piggyback sig: as directed intravenous hd protocol (hd protochol): 1 gram per hd protocol, total 2 week course, last day is . discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: hemorrhagic shock esrd strep viridans bacteremia discharge condition: stable discharge instructions: you were admitted because your blood pressure was low because you were bleeding from your leg wounds. this was complicated by the fact that your blood was too thin while you were on coumadin. your inr (coumadin level) needs to be monitored very closely after you leave and should be in the range of . you should continue your dialysis as an outpatient and your local wound care. our nurses will send the wound care recommendations to your nursing home or rehab for the nurses there to help with your daily wound care. please call your doctor or return to the emergency room if you have chest pain, worsening pain in your leg, bleeding, or any other symptoms that worry you. followup instructions: please follow up with your primary care physician 2 weeks of your discharge from the hospital. you will have dialysis at 11a.m. on saturday at the kidney center and the following tues / thurs / saturday at the in . you will continue to receive vancomycin dosed at your dialysis sessions until for a total 2 week course for 'simple bacteremia.' please follow up with the first available appointment for plastic surgery at the . call the following number to set up this appointment, the nursing home can help you with this. ( md, procedure: diagnostic ultrasound of heart hemodialysis venous catheterization for renal dialysis nonexcisional debridement of wound, infection or burn phlebography of other specified sites using contrast material diagnoses: end stage renal disease obstructive sleep apnea (adult)(pediatric) pure hypercholesterolemia acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled other shock without mention of trauma bacteremia pressure ulcer, other site long-term (current) use of anticoagulants pressure ulcer, lower back personal history of venous thrombosis and embolism streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus ulcer of other part of lower limb chronic ulcer of other specified sites 

Answer: The patient is high likely exposed to