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: patient recorded as having no known allergies to drugs attending: chief complaint: 80 yo m with hx of alcoholic cirrhosis and varices who presented with gi bleedindg, fever, hypotension, and le cellulitis. major surgical or invasive procedure: 1. upper endoscopy 2. sigmoidoscopy history of present illness: 79 yo m w/ a h/o etoh cirrhosis, rectal cancer s/p chemotherapy and xrt, h/o ugib s/p variceal banding in , chronic lle ulcer, who initially presented to osh w/ fever, hypotension, and le cellulitis. before admission to osh, found by wife standing in the kitchen incontinent of stool and not responding to her. alert per emt reports. . patient admitted to osh and treated for his cellulitis w/ iv zosyn. bp in 80s/30s on admission and given 1l ns bolus which brought his bp up to the 100s. at osh he was noted to have bm x1 with old, clotted blood. his hct on admission to osh was 34, which then drifted down to 26. transfused 2u prbc. no hematemesis, hemodynamically stable. . transferred to for further care given he was seen here in past for variceal banding. in micu, hct stable. started on iv ppi and transient octreotide. seen by liver team, s/p egd showing non-bleeding grade iii esophageal varices. 3 bands placed by liver . plan is for flex sigmoidoscopy this morning. per micu team, patient also had episodes of asymptomatic bradycardia to 30's while sleeping. ep curbsided and recommended of hearts monitor as an outpatient. while in micu, patient treated with zosyn for lle cellulitis. blood cxs from osh now positive group c strep. wound cx positive for pseudomonas. . after transfer to floor, rn report, patient had small amount of brbpr after 3rd enema. patient remained asymptomatic. following morning patient continues to deny lightheadedness, blurry vision, cp, sob, abdominal pain. past medical history: 1. rectal cancer - diagnosed in - s/p chemotherapy - s/p xrt x 3, with resulting radiation proctitis - elected not to have surgery b/c did not want a colostomy 2. etoh cirrhosis with portal htn - has had esophageal and gastric varices - several episodes of variceal bleeds, most recently in which required banding - 4 bands here. 3. peripheral vascular disease -fem-fem bypass in 4. diabetes, diet controlled social history: former etoh abuse, last drink yrs ago. former tobacco abuse, pk/d x 58 yrs. lives with wife. has 3 children. family history: non-contributory physical exam: vs - t=97.7; bp=142/50; hr=52; rr=18; o2=96%ra fsbg 75 gen: awake, alert, interactive. nad heent: op clear. sclera anicteric. neck: jvp ~ 8 cm cv: rrr, normal s1/s2, distant heart sounds, no murmurs. r sided port-o-cath c/d/i. lungs: crackles at l base. otherwise, ctab abd: nabs. asymmetrically distended, l>r. no tenderness to palpation. no rebound or guarding. no hsm. ext: lle - +erythema to knee. tracking to groin resolved. large stage 3 ulcer on inner left foot. stage 2 ulcer on l lower shin. rle - there is erythema on the dorsum of his r foot. no ulcers. neuro: cn2-12 intact, a&ox3, no asterixis. pertinent results: 09:10pm glucose-90 urea n-46* creat-1.1 sodium-138 potassium-3.3 chloride-104 total co2-25 anion gap-12 09:10pm alt(sgpt)-24 ast(sgot)-37 ld(ldh)-184 alk phos-62 tot bili-1.6* dir bili-0.7* indir bil-0.9 09:10pm albumin-2.9* calcium-8.1* phosphate-3.1 magnesium-2.2 09:10pm tsh-2.6 09:10pm wbc-9.9# rbc-3.30* hgb-10.7* hct-30.7* mcv-93 mch-32.5* mchc-34.9 rdw-15.5 09:10pm hypochrom-normal anisocyt-normal poikilocy-1+ macrocyt-normal microcyt-normal polychrom-normal ovalocyt-1+ elliptocy-1+ 09:10pm plt count-58* 09:10pm pt-17.3* ptt-35.9* inr(pt)-1.6* 09:10pm fibrinoge-440* 03:55am blood wbc-8.2 rbc-3.22* hgb-10.6* hct-29.6* mcv-92 mch-32.9* mchc-35.7* rdw-15.6* plt ct-46* wbc rbc hgb hct mcv mch mchc rdw plt ct 09:04am 26.4* 05:30am 2.4* 2.58* 8.4* 24.0* 93 32.4* 34.8 14.8 67* 12:24pm 28.1* 06:00am 2.3* 2.74* 8.9* 25.3* 92 32.6* 35.3* 14.7 69* 07:25am 2.5* 2.89* 9.4* 26.7* 92 32.5* 35.2* 14.8 57* 07:48am 2.9*# 2.93* 9.5* 27.1* 93 32.5* 35.1* 14.8 56* 05:26am 6.6# 2.95* 9.4* 27.1* 92 32.0 34.9 14.8 64* renal & glucose glucose urean creat na k cl hco3 angap 05:30am 91 19 1.0 134 4.1 103 25 10 06:00am 89 21* 1.0 136 4.0 103 27 10 05:48am 84 22* 1.1 135 4.2 100 27 12 07:25am 80 21* 1.0 134 3.6 99 28 11 03:15pm 3.8 07:48am 79 22* 1.0 136 3.2* 103 24 12 05:26am 171* 25* 1.2 136 4.0 101 28 11 added & lip at 9:47am on 07:05am 92 21* 1.0 136 3.6 100 28 12 06:23am 101 19 0.9 137 3.7 102 26 13 crp added 10:22am 06:08pm 3.9 06:38am 92 21* 0.9 137 3.0* 102 26 12 05:15am 126* 23* 1.0 140 3.4 108 22 13 05:45am 95 23* 0.9 136 3.4 104 24 11 04:39am 157* 35* 1.0 136 3.7 104 26 10 03:55am 141* 42* 1.1 137 4.1 105 23 13 09:10pm 90 46* 1.1 138 3.3 104 25 12 basic coagulation ( pt ptt plt ct inr(pt) 05:30am 67* 06:00am 69* 05:48am 73* 05:48am 12.7 36.7* 1.1 07:25am 57* 07:25am 13.6* 39.1* 1.2* 05:26am 14.7* 44.1* 1.3* 12:03pm 13.9* 80.9* 1.2* 07:05am 55* 07:05am 14.1* 57.0* 1.3* 06:38am 43* 06:38am 13.6* 36.6* 1.2* 05:15am 47* 03:55am 46* 03:55am 15.2* 36.6* 1.4* 09:10pm 58*1 09:10pm 17.3* 35.9* 1.6* radiology bilat lower ext veins. no evidence of lower extremity dvt. ct pelvis w/contrast ct chest with iv contrast: the airways are patent to the segmental level. there are bilateral small pleural effusions greater in the left side. there is continuos linear calcification in the inferior and posterior aspect of the right pleura. small focal calcifications are seen in the posterior and inferior left pleura. aside from a few subsegmental atelectases in the bases, the lungs are clear. the lad, left circumflex and right coronary arteries are heavily calcified, cardiac size is top normal. otherwise the aorta and great vessels are unremarkable. multiple paratracheal lymph nodes measure up10/4 to 7 mm, they do not meet ct size criteria for pathologic enlargement. a 9 mm lymph node is seen in the right hilum. in the abdomen, the liver has nodular contour with moderate decrease in the size of the right lobe keeping with patient's known cirrhosis. in the upper pole of the spleen there is a subcentimeter hypodense lesion too small to be characterized. there are esophageal varices. the gallbladder is mildly distended. the pancreas, adrenal glands and left kidney are unremarkable. in the medial aspect of the upper pole of the right kidney there is a subcentimeter hypodense lesion too small to be characterized. there is no mesenteric or retroperitoneal lymphadenopathy. there is a small quantity of perisplenic and perihepatic free fluid. extensive calcifications are present in the celiac axis, the splenic artery, the ostium of both renal arteries and in the sma. a infrarenal abdominal fusiform aneurysm measures up to 34 x 33 mm. extensive calcifications are seen in both common iliac arteries greater in the right side. there is moderate splenomegaly, the spleen measures up to 17 cm ap. the bowels are unremarkable. pelvic ct: there is no free fluid or lymphadenopathy. coarse calcifications are seen in the prostate gland. the bladder is unremarkable. the sigmoid colon is unremarkable. the bifemoral bypass is patent. there is a 37 x 20 mm fluid collection in the right inguinal region (3:113). art dup ext lo uni;f/u; art ext (rest only)findings: duplex evaluation was performed of the femoral-femoral bypass graft. the velocities in the graft are 99 to 104 cm/sec. right femoral anastomosis and native artery is 169 and 81 cm/sec respectively. left corresponding velocities are 118, 135 cm respectively. doppler waveforms are monophasic at all levels from the femoral to the dorsalis pedis artery. the ankle brachial index is 0.82 on the right and 1.1 on the left. pulse volume recordings on the right show mild drop-off at the thigh compared to the opposite thigh, continued drop-off at the calf and metatarsal. on the left, pvrs are relatively maintained to the calf level and show significant drop-off at the ankle and metatarsals. impression: widely patent femoral-femoral bypass graft without evidence of stenosis. on the right side, there appears to be significant sfa and tibial artery occlusive disease. on the left, there is also severe sfa and tibial artery occlusive disease with a severe flow deficit to the forefoot. mr left ankle with and without contrast: tendons: the peroneal, achilles, and extensor tendons are unremarkable. incidental note of a peroneus quartus tendon is made, a normal variant. there is edema seen in the plantar soft tisues of the foot with a small amount of fluid around the flexor hallucis longus tendon representing tenosynovitis. diffuse subcutaneous edema is noted. ligaments: all of the ligaments are intact including the medial, lateral, and lisfranc ligaments. soft tissue and osseous structures: there is a soft tissue ulceration over the medial malleolus. there is a slight increased t2 signal in the medial malleolus. there is no evidence of an abscess or cortical destruction. osteonecrosis in the lateral aspect of the talar dome is seen. the joint spaces are preserved. no fractures or dislocations are visualized. the ankle mortise is congruent with the talus. impression: 1. soft tissue ulceration over the medial malleolus. corresponding nonspecific increased t2 signal in the medial malleolus. there is no evidence of abscess or cortical destruction. the findings are nonspecific and could be seen in reactive change, although early osteomyelitis cannot be excluded. no soft tissue abscess. 2. osteonecrosis of the talar dome. 3. tenosynovitis of the flexor hallucis longus tendon. liver or gallbladder us findings: the gallbladder is distended and partly filled with sludge and some shadowing stones. there is no son sign, however, and the wall is not thickened. there is no intramural edema or pericholecystic fluid. there is no intra- or extra-hepatic biliary ductal dilatation. the liver has a coarse appearance consistent with the history of cirrhosis. there is no ascites. the pancreas is not well seen because of overlying bowel gas. impression: distended gallbladder with stones and sludge, but no other ultrasound findings suggestive of cholecystitis. correlation with clinical factors is suggested, however, and if there is continued clinical concern for cholecystitis, a hida scan could be performed in order to evaluate for gallbladder filling. transthoracic echo conclusions: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic root, ascending aorta, and the aortic arch are mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is a 0.8 x 0.3 cm linear density on the ventricular side of the anterior mitral leaflet, which likely represents a torn chorda tendinae. however, a vegetation cannot be definitely ruled out. there is no significant associated mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no definite transthoracic echo evidence of endocarditis. mildly dilated thoracic aorta. mild aortic regurgitation. a transesophageal study may better define the linear mitral valve density and assess for possible vegetations. transesophageal echo conclusions: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the 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. physiologic mitral regurgitation is seen (within normal limits). there are redundant mitral valve chordae but no evidence of endocarditis. there is no pericardial effusion. impression: no abscess or vegetations seen. redundant mitral valve chordae. brief hospital course: 80 yo m w/ etoh cirrhosis and known varices, presents w/ cellulitis, bacteremia, and gib now being evaluated for possible persistent bacteremia and osteomyelitis 1. gib: patient came in hypotensive and guaiac positive stool. an egd was ordered to r/o any upper gi sources. egd found unlikely to be an ugi bleed since there were no bleeding vessels identified. grade iii varices were identified and esophageal banding was placed for bleed prevention. flex sigmoidoscopy was obtained to find any lower gi bleeding and found inflammatory changes in the rectal mucosa consistent with radiation proctitis--likely causing his gi bleeding. hematocrit stabilized by hd 2. he had some guaiac positive stools on hd 3, but no further guaiac positive stools at time of discharge. pt will need to f/u in 4 weeks with gi at or for further banding. appointment already scheduled at . . 2. bacteremia: bacteremia was likely caused by ulcer infection. cultures on at revealed 2 bottles positive for gram + cocci (group c strep). gp c strep was sensitive to pcn, erythromycin and clindamycin. follow-up blood culture on was negative for organisms. pt had a port-o-cath in place, presumably from previous chemotherapy. since group c strep was cultured from ulcer site, it seemed less likely that bacteremia derived from cath infection. pcp was and it was found that the patient was no longer in need of port cath. blood cultures were drawn for worsening cellulitis on . iv zosyn started. on , patient spiked fever of 101.7. port cath was removed in suspicion of bacteremia. iv antibiotics continued. blood cultures were drawn to exclude any bacteremia. patient has remained afebrile through . on tte was obtained in order to rule out any cardiac vegetations. results of the tte showed mild aortic regurgiation and ruptured mitral cordae. picc line was placed for access of iv abx. on , patient had a tee which showed no abscess or vegetations. redundant mitral valve chordae. in preparation for discharge, picc line was removed and patient was discharged on oral antibiotics. blood cultures remained negative at this institution. . 3. cellulitis/chronic ulcers: cellulitis most likely the result of chronic le ulcers from pvd s/p fem-fem bypass in . arterial duplex son study of le was ordered on as recommended by vascular surgery. test revealed widely patent femoral-femoral bypass graft without evidence of stenosis. on the right side, there appears to be significant sfa and tibial artery occlusive disease. on the left, there is also severe sfa and tibial artery occlusive disease with a severe flow deficit to the forefoot. vascular surgery recommended no acute inpatient intervention or revascularization for this problem. they recommended that patient follow-up as an outpatient. wound cultures from outside hospital revealed infection by group c strep and pseudomonas. pseudomonas found to be pan sensitive. group c strep was also pan sensitive. zosyn was discontinued on and was started on oral keflex and cipro. on lle became more erythematous and warm. patient also reported increased pain. there was a question of worsening cellulitis and insufficient coverage by oral antibiotics. oral abx were d/dc'ed and he was started on zosyn 4.5 gm iv. lle erythema continued to improve on iv antibiotics. by day of discharge, lle was diffusely pink up to proximal third of lower leg, greatly improved from admission. he had completed 14 day course of iv zosyn and was transitioned to oral levofloxacin at the recommendations of infectious diseases. patient will be discharged with vna assistance for dressing changes and wound care. his qt interval will need to be monitored by ekg while on levofloxacin as he has a baseline prolonged qtc. . 4. osteomyelitis: on x-ray of the left ankle was obtained. x-ray revealed periosteal reaction and bone sclerosis about the ulcer site consistent with osteomyelitis. crp was 9 and esr 19, consistent with chronic osteomyelitis. the orthopedic service was consulted and recommended foot and ankle mri. results of the mri showed soft tissue ulceration over the medial malleolus with underlying nonspecific bone marrow edema in the medial malleolus. they also found osteonecrosis of the talar dome. these findings were consistent with early chronic osteomyelitis. orthopedics concluded that because mri did not show any signs of abscess or sequestra, patient did not require surgical debridement. they recommended treatment with iv antibiotics as per id recommendations. infectious disease recommended that the patient be discharged on a regimen of po levaquin for adequate coverage of his osteomyelitis as he had already completed a 14 day course of iv antibiotics. they suggested that the patient remain on levaquin indefinitely until more definitive treatment can be done by vascular surgery in the outpatient setting. as above, his qtc will need to be monitored while on levofloxacin. . 5. fever/nausea/transaminitis: on , patient reported ruq pain with n/v and rising fevers. he had one bout of emesis. blood test revealed elevated liver transaminases, bilirubin, alk phos, amylase and lipase. symptoms improved overnight. he had a negative sign. on he underwent ruq ultrasound that found a distended gallbladder with sludge and stones. there was no sign of acute cholecystitis. findings were suggestive of a passing stone, rather than acute cholecystitis or pancreatitis. over the course of his hospital stay, lfts continued to trend down. by the time of discharge, lfts had come down to within normal limits. he had no further episodes of fever, ruq pain, or nausea for the rest of the hospital stay. patient should be evaluated as an outpatient for an elective cholecystectomy. . 6. hypotension: patient had episodes of hypotension on with heart rate in the 60's. hypotension was likely the result of hypovolemia secondary to poor po intake the day prior. 500 cc bolus was given overnight and pressure raised 124/80. he had no further episodes of hypotension throughout the rest of the hospital stay. . 7. cirrhosis: pt has been diagnosed with cirrhosis for approx. 7 years. home therapy includes nadolol, aldactone, and bumetidine. pt has hepato-spleno megally on exam. he is oriented x3 with no asterixis. he has grade 3 esophageal varices and internal hemorrhoids, as confirmed by endoscopy. patient has been doing well while maintained on home regimen of nadolol, bumetidine, and aldactone. ruq us on showed no ascites. pt was scheduled for outpatient visit with gi for banding of esophageal varices. he should continue home regimen of nadolol, aldactone and bumetidine for management of cirrhosis. . 8. dm: diabetes is well controlled on home with diet. while in house, some glucose levels have been outside of ideal control. he had no episodes of hypoglycemia. he was placed an insulin sliding scale and had nor further issues on hyperglycemia during the rest of the hospital stay. . 9. pancytopenia: patient has been noted to be chronically pancytopenic. daily cbc's were drawn to monitor pancytopenia and values remained stable throughout hospital stay. etiology of pancytopenia is unknown, but probably related to cirrhosis versus systemic infection leading to bone marrow suppression. pancytopenia should be evaluated as outpatient by pcp. . 10. bradycardia: episodes of asymptomatic bradycardia in micu. ep curb sided and recommended of hearts monitor as an outpatient. no further episodes of bradycardia while on nadolol for the rest of the hospital stay. patient will likely need a of hearts monitor after d/c. to be followed up by pcp . 11. anemia: baseline hct around 30. hematocrit ranged from 34.6 to 29.5. for most of the hospital stay, hct remained consitantly around 30. he was found to have low iron and normal ferritin as as normal b12 and folate. he is likely iron deficiency anemia with reactive ferritin vs. anemia of chronic disease. pt was placed on iron supplements while in house. he should continue iron supplementation at home. medications on admission: - aldactone: 25mg - prilosec 20mg - nadolol 20mg - bumetinide - 1mg - mvi daily - fe daily - morphine sulfate: 30mg prn discharge medications: 1. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 2. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 3. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 4. bumetanide 0.5 mg tablet sig: two (2) tablet po bid (2 times a day). 5. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 6. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. multi-vit 55 plus tablet sig: one (1) tablet po once a day. 8. levofloxacin 500 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*4* 9. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). disp:*60 tablet sustained release(s)* refills:*0* 10. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary: 1. gastrointesitnal bleeding 2. radiation proctitis 3. cellulitis . secondary: 1. cirrhosis 2. rectal cancer 3. peripheral vascular disease 4. diabetes 5. osteomyelitis discharge condition: stable discharge instructions: please continue to take all medications as prescribed. you will need to continue to take levofloxacin once daily indefinitely. . please follow up with dr. as below. you should have a repeat ekg to monitor your qt interval as it was prolonged during your hospital stay and you are now on levofloxacin which can increase your qt. . you will need to follow up with gastroenterology to repeat an upper endoscopy for variceal banding as below. you have been scheduled for one at . if you would prefer to have this completed closer to home, please call your local gastroenterologist to schedule and then cancel your appointment. . you have also been scheduled for follow up with the infectious diseases department at to follow your bone infection. if this appointment is difficult for you, you should be sure to have close follow up for your bone infection through your primary care provider. . you should also follow up with vascular surgery as specified below for continuing care of your ulcers. . please call your doctor or return to the hospital if you experience bloody stools, dark tarry stools, chest pain, shortness of breath, lightheadedness, abdominal pain, increased abdominal size, or any other concerns. followup instructions: please return to to have a repeat upper endoscopy on the of the building on . you will need to arrive by 8 am for a 9am procedure. you should not eat or drink anything after midnight the night prior. you should not take aspirin or ibuprofen for 1 week prior to the procedure. you will need a ride home the day of the procedure. you should be done around 12 noon. . please follow up with your primary care provider . on at 1:30 pm. phone: (. . please follow up with dr. from vascular surgery at on wed :45 am. his office is located in the suite 5c. . you have been scheduled to follow up with infectious diseases regarding your osteomyelitis and bacteremia. please attend your appointment on at 930 am in of the . procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart endoscopic excision or destruction of lesion or tissue of esophagus flexible sigmoidoscopy incision with removal of foreign body or device from skin and subcutaneous tissue diagnoses: diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled alcoholic cirrhosis of liver other and unspecified alcohol dependence, in remission portal hypertension other specified cardiac dysrhythmias cellulitis and abscess of leg, except foot bacteremia hemorrhage of gastrointestinal tract, unspecified esophageal varices in diseases classified elsewhere, without mention of bleeding calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction atherosclerosis of native arteries of the extremities with ulceration pseudomonas infection in conditions classified elsewhere and of unspecified site radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure chronic osteomyelitis, ankle and foot personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus ulcer of ankle rupture of chordae tendineae ulcerative (chronic) proctitis streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group c 

Answer: The patient is high likely exposed to