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: nafcillin / vancomycin attending: chief complaint: back pain due to epidural abscesses complicated by bacteremia and acute respiratory distress major surgical or invasive procedure: 1. . cervical decompression via laminectomies c2-c6 bilaterally, insertion of 2 epidural drains. laminectomy t12-l1-l2, insertion of 2 drains 2. right knee arthrocentesis and washout 3. anterior cervical discectomy and fusion as well as epidural abscess evacuation. 4. ir-guided paraspinal abscess drainage history of present illness: 54 yo f presents to ed w/ 1 week of worsening back pain. pain reportedly started while riding a bike. began in lower back and has steadily risen up to her neck over the past week. also reports some shooting pain down right leg. + fevers and chills. for the past 3 days, her legs have been feeling weak, she has had difficulty urinating. fevers and chills have resolved. reports tremors starting two days ago. she denies fecal incontinence although this was reportedly endorsed to ed staff. denies any numbness or tingling in her extremities. past medical history: none social history: works for a mission network. no ivda. social etoh family history: n/c physical exam: admission physical exam: t:98.7 bp: 155/100 hr:140-150s rr: 20 o2sats 100% on nrb gen: anxious, uncomfortable heent: pupils: 4->3 eoms - full abd: soft, nt extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. motor: d b t we wf ip q h at g r 5 5 5 5 5 5 5 5 5- l 5 5 5 5 5 5 5 5 5- sensation: intact to light touch, propioception, pinprick and vibration bilaterally. reflexes: pa ac right 2+ mute left 2+ mute rectal exam - normal sphincter control, normal perianal sensation discharge physical exam (): vs: afebrile >36hr, tc: 98.1 bp: 130/76 (140-170/80-92) 94% 2l 02 saturation yesterday: 97--100% on 1-2l; 94% ra gen: sleeping but arousable, oriented, no acute distress heent: non-icteric sclera, mmm neck: gauze and tegaderm in place over former rij, no tenderness heart: rrr, nl s1 s2, 3/6 systolic murmur, heard best at lusb, radiating to neck bilaterally, no rubs lungs: anterior lung fields clear, slightly decreased bs at bases, no wheezes abd: ecchymoses on lower abdomen, +nabs, soft, non-distended, non-tender, without rebound or guarding ext: warm, 1+ edema to ankle b/l, right knee with healed surgical scar t/l/d - left picc line in place; no surrounding tenderness, erythema pertinent results: admission labs: 01:45pm urine rbc-* wbc->50 bacteria-many yeast-none epi-0-2 01:50pm wbc-21.2* rbc-4.70 hgb-14.2 hct-43.9 mcv-93 mch-30.2 mchc-32.4 rdw-14.4 01:50pm glucose-287* urea n-51* creat-1.7* sodium-136 potassium-3.6 chloride-96 total co2-21* anion gap-23* 02:17pm lactate-2.9* discharge labs () wbc rbc hgb hct mcv mch mchc rdw plt ct 16.6* 2.87* 8.0* 24.4* 85 27.8 32.7 17.9* 227 diff neuts bands lymphs monos eos baso atyps metas myelos promyel nrbc 59 9* 8* 21* 0 0 1* 2* 0 glucose urean creat na k cl hco3 angap 96 22* 0.5 141 3.7 102 32 11 inflammatory markers () esr: 115* crp: 30.9 . micro: micro: - blood cx - mssa - epidural swab - mssa - joint fluid + swab - mssa - epidural swab - mssa abscess - mssa . c. diff - (-), (-), (-), (-) . antimicrobial history: vanco+cefepime -> vanco -> nafcillin -> vanco -> cefepime -> meropenem 1000mg iv q8 ( - ) daptomycin 600mg iv q24 ( - present) 10:22 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). imaging: mri spine : 1. cervical anterior epidural collection, with severe narrowing of the thecal sac from c2 through c5, without evidence of spinal cord edema. sagittal post-contrast images suggest that this collection contains fluid at the level of c2, which would indicate an abscess rather than a phlegmon. however, axial post-contrast images suggest that the central hypoenhancing portion of the collection at c2 may not be fully liquefied, or that the fluid may be highly viscous. 2. anterior epidural collection from t11 through the upper sacrum, compressing the thecal sac and crowding the cauda equina. this collection appears to contain fluid from t12 through l3, indicative of an abscess rather than a phlegmon. 3. no evidence of discitis or osteomyelitis. 4. bilateral posterior paravertebral muscle phlegmon at the level of l4-5 with a possible 5 mm abscess on the right. contrast enhancement surrounding the l4-5 facet joints may represent inflammation secondary to the severe degenerative facet arthropathy, but septic facet arthropathy cannot be excluded echo : impression: suboptimal image quality. mild mitral leaflet thickening but without discrete vegetation or pathologic flow. mild pulmonary artery systolic hypertension. normal left ventricular cavity size with preserved global and regional systolic function mri spine : 1. cervical region: no stir signal abnormality in the cord. no evidence of cord compression. expected post-op changes. 2. lumbar region: small epidural signal abnormality, could represent residual abscess collection from debridement or post-surgical changes. xray-knee impression: small to moderate-sized knee joint effusion. cta impression: 1. no pulmonary embolism or acute aortic pathology. 2. moderate bilateral pleural effusions with subtotal lower lobe collapse. evidence of loculated pleural effusions tracking up in the right upper lateral pleural space. 3. multiple lung nodules likely infectious in this cl inical setting. follow- up to resolution is recommended 4. no pneumothorax. mr significant increase in volume of the epidural fluid collection/abscess extending from the uppermost c1 epidural space to the inferior aspect of the study at l1, largest at the upper cervical spine where it measures approximately 1 cm in greatest thickness. the patient is status post cervical laminectomy from approximately c2-c6 but the epidural collection displaces the cervical cord posteriorly and the cervical cord appears compressed against the posterior ring of c1. there is increased signal within the cervical cord from the medulla to c3. 2. the epidural collection/abscess within the thoracic spine mildly displaces the thoracic cord without evidence of cord signal abnormality. ct-thoracentesis (drainage) impression: successful diagnostic and therapeutic thoracentesis yielding 270 cc of serosanguineous fluid from the right pleural cavity. an 8 french pigtail catheter was placed within the pleural cavity and is currently attached to waterseal. samples were sent for microbiology and chemistry per the ordering team's request. mr c/t/l-spine impression: 1. new soft tissue paraspinal pockets of fluid collection are seen in the lumbar region since the examination of and , visualized in the lower lumbar region involving the psoas muscles and the erector spinae muscles. the largest collection in the right erector spinae muscle is approximately 3 cm and the largest collection in the right psoas muscle is approximately 2 cm. additional left psoas muscle fluid pocket measures 2.8 cm. smaller foci are also visualized. 2. lumbar epidural fluid collection ventral and dorsal to the thecal sac in the lower lumbar region may be slightly smaller compared to . 3. epidural collection in the cervical region extending from c2 inferiorly is not significantly changed since the mri of . minimal indentation on the spinal cord in cervical region is unchanged. postoperative changes and laminectomies are seen in this region. 4. thoracic epidural collection has not changed and there is no cord compression in thoracic region. 4. laminectomies are seen in the lower thoracic/upper lumbar region. thin rim of epidural collection again seen in the thoracic region which is unchanged. no cord compression is identified in the thoracic region. ct-chest/abdomen/pelvis impression: 1. overall, stable appearance of multiple small fluid collection seen in the paraspinal muscles along with the erector spinae and psoas muscles, as described above. no new intraabdominal or intrapelvic collections identified. 2. stable bilateral pleural effusion with bibasilar airspace disease. 3. stable appearance of mediastinal and bilateral hilar lymphadenopathy. u/s abdomen impression: 1. cholelithiasis with edematous and thick walled but contracted gallbladder. no son evidence of acute cholecystitis. gallbladder wall thickening and edema may be caused by multiple factors such as liver disease and hypoalbuminemia, and clinical correlation is recommended. 2. splenomegaly. ct-chest/abdomen/pelvis impression: 1. multiple soft tissue abscesses appear similar to prior examination with erector spinae abscess on the right, left iliopsoas abscess, and fluid pockets overlying the lower lumbar spine spinous processes. 2. left posterior rotator cuff region possible new abscess, not well seen on prior studies. 3. bilateral basal pulmonary volume loss and consolidation, similar to prior examination in lesion addition to bilateral pleural effusions, more pronounced and somewhat loculated on the right but similar to prior study. 4. nonspecific gallbladder wall thickening. cholecystitis is not excluded, although the appearance is stable compared to prior examination and has been previously evaluated with ultrasound. 5. nonspecific lesion in the right renal upper pole. this was not well seen on prior examination. if there is clinical suspicion for renal abscess, targeted ultrasound could be performed to further assess. 6. left proximal thigh abscess, incompletely assessed but similar to prior study allowing for difference in technique. 7. splenomegaly. mri c-spine impression: again, epidural enhancement and abscesses identified in the anterior cervical region. as described above, the fluid collection around c2-c3 level appears slightly increased in thickness, but the differences in measurements are small and this could also be due to partial volume averaging, but continued followup is recommended. otherwise, the examination is stable mri t-spine impression: overall stable appearance of the thoracic spine compared to the previous mri of . again, lower thoracic and upper lumbar laminectomies and epidural enhancement is seen in the thoracic region without epidural abscess. ct scan abd/pelvis (): with abdominal pain of unclear etiology, look for possible underlying abdominal abscess. comparison: ct torso from . technique: non-contrast mdct of the abdomen. the patient not received any oral or iv contrast. findings: of note, evaluation of abdominal organs is limited without any intravenous or oral contrast administered. once again, there are bilateral pleural effusions with overlying collapse/consolidation that has slightly improved from previous study. once again, the right is significantly greater than the left and appears loculated. a nodular density previously seen in the right middle lobe is not visualized in the current study. ct abdomen w/o contrast: there is no focal liver lesion seen. there is evidence of a large stone within the gallbladder; however, there are no signs of gallbladder wall thickening or other associated signs to suggest inflammation or infection. the spleen is enlarged. there is no focal splenic lesion or abscess seen. pancreas appears normal. adrenals appear normal. the kidney is normal in appearance. right kidney appears normal in appearance. the small area of hypoattenuation seen in the left kidney on the previous study was not appreciated on the current exam. small periaortic and portacaval lymph nodes are again seen, however, they do not meet ct criteria for lymphadenopathy. there is no bowel obstruction. the appendix is normal. there is no significant mesenteric lymphadenopathy or fluid collection seen. ct pelvis w/o contrast: once again seen is a low-attenuation fluid collection in the left iliopsoas muscle, extending from the lower lumbar-upper pelvic regions along the psoas. this collection appears unchanged, both in size and in character and further characterization is limited without contrast. once again seen are the small areas of low attenuation, representing fluid in the proximal thigh as well as stranding in the left greater trochanter. this appears unchanged from the previous study of . there is no epidural abscess seen in the thoracic region. the rectum, sigmoid colon, bladder, and uterus are normal. 3d reconstructions, coronal and sagittal reconstructions were essential in delineating the anatomy and pathology. bones: there is no osseous destruction seen. as mentioned, evidence of priorlaminectomies at the lower thoracic spine and upper lumbar spine are seen.there are no epidural collections suggestive of epidural abscess in the lumbaror visualized thoracic spine. impression: 1. unchanged left iliopsoas abscess 2. slight interval decrease in bilateral basal pulmonary volume loss and consolidation and pleural effusions. 3. large gallstone within the gallbladder without sign of gallbladder inflammation. 4. unchanged fluid collection in the left proximal thigh compared to prior. 5. this study was discussed with dr. at 4:30 p.m. on . . unilateral upper extremity venous ultrasound. () comparison: upper extremity venous ultrasound . findings: color and grayscale son of bilateral subclavian and left-sided internal jugular, basilic, brachial and cephalic vessels were evaluated. evaluated vessels demonstrated normal flow, compressibility and augmentation. there is a picc line in the basilic. there is duplication of the brachial vessels. impression: picc in the basilic vein but no dvt. . brief hospital course: ms is a 54 yo female with no significant past medical history who initially presented with back pain, urinary retention on , found to have multiple epidural abscesses s/p multiple surgical debridements with hospital course complicated by episodes of flash pulmonary/respiratory compromise requiring intubation and febrile neutropenia secondary to lasix and vancomycin administration. . # bacteremia/abscesses/antibiotic therapy . patient initially presented with back pain, associated urinary retention and le weakness. admission imaging positive for cervical and lumbar epidural abscesses (though patient with no known risk factors). she was empirically started on vancomycin/cefepime/levofloxacin. she underwent c2-c6/t12-l2 bilateral laminectomies with insertion of 4 drains on . she subsequently developed a septic right knee and returned to the or on for right knee washout. regarding further initial infectious work-up at that time: a tee was obtained which showed no vegetations; ct head without evidence of intracranial abscess. . on , antibiotic coverage was narrowed to nafcillin when cultures from abscesses, right knee, and blood grew mssa. however, due to signs and symptoms of leukocytosis, hypoxia there was concern for hospital acquired pneumonia and antibiotic coverage was broadened to vancomycin, cefepime, and ciprofloxacin on . patient remained febrile. surveillance imaging obtained on which demonstrated increased epidural collection within anterior cervical epidural space and displacement of the cervical cord. the patient returned to the or on for abscess decompression and evacuation and fusion of c3-4, c4-5, and c5-6. after reviewing microbial date with all cultures + mssa, her antibiotic coverage was again narrowed to nafcillin. . patient had been doing well with normalized temperature and wbc however four days after starting nafcillin, developed a abdominal rash. derm was consulted, biopsies were taken which were c/w drug rash secondary to nafcillin. nafcillin was subsequently discontinued and replaced by iv vancomycin. . repeat mr spine with new paraspinal fluid collections, and mild epidural fluid collection throughout the spine. due to concern for continued infection cefepime was added to antibiotic regimen. on , the patient underwent paraspinal abscess drainage by interventional radiology. follow-up ct torso was obtained on due to persistent fevers on cefepime and vanc; finding were stable to previous imaging and cefepime was discontinued. on , her c-collar was removed. surveilance mr c/t-spine on showed stable epidural enhancement and abscesses identified in the anterior cervical region, thoracic region without epidural abscess. ct scan on demonstrated left iliopsoas abscess/phlegmen and left thigh fluid collection; both of which were too small to be drained by ir. . unfortunately side effects necessitated further antibiotic adjustment. cbc with noted leukopenia on with progression to neutropenia . out of concern that vancomycin could be contributing to decreasing counts, vanc d/c'ed and iv daptomycin started. per id will plan to treat mssa bacteremia/abscesses with iv daptomycin to total of 6-8wk course. at time of discharge utility of repeat imaging discussed. plan to repeat ct abd/pelvis; mri spine further into antibiotic treatment. . # febrile neutropenia . patient's wbc count began to slowly decline on with progression to neutropenia on . neutropenia was felt secondary to medication effect; subsequently omeprazole, furosemide, vancomycin and seroquel were discontinued. hematology was consulted, and felt that furosemide or vancomycin were likely offending agents. antibiotic coverage altered on : vancomycin discontinued and daptomycin started for treatment of mssa. on she was febrile 102.6 and meropenem started for treatment of neutropenic fever. gcsf initiated. after administration of gcsf counts slowly became to rise and fevers abated. gcsf was stopped on when anc>1000 for more than 48hrs. . respiratory distress . on admission patient found to be tachypnic. lenis negative. on , developed worsening tachypnea and hypoxemia (95% on 4l by nasal canula). the patient diureased 500ml on iv lasix and improved slightly. cta ruled out pe, however showed evidence of bilateral loculated pleural effusions and multiple lung nodules. cardiac enzymes negative. pro-bnp 2777 on . estimated ef by tee was >55%; 2 repeat echos without evidence of valvular pathology. in micu, iv lasix and morphine lessened respiratory distress. on , transferred to the floor; latered became hypoxic and was transfered back to the micu and started on bipap. pleural effusion studies suggested parapneumonic effusion. patient intubated and extubated several time while in micu. on , the patient was again extubated. she developed hypertension to 180 sbp and respiratory distress secondary to pulm edema, which responded to lasix and labetolol. on , she was comfortable oxygenating with only nasal cannula. she was electively intubated on for paraspinal abscess drainage and extubated post-procedure. unfortunately, again developed worsening hypercarbic respiratory distress, requiring reintubation on . she was gently diuresed, in an effort to decrease the work of breathing. on she was succesfully extubated, satting well on face mask. on she was weaned to nc. ct on showed improvement in pleural effusions and basilar consolidations. she continued to do well on supplemental oxygen by nasal cannula. on the floor her oxygen requirement was weaned. she had one episode of flash pulmonary edema, during which she desaturated to high 80s. she was diuresed with bumex with good effect. for the remainder of her stay, team allowed for auto-diuresis. at time of discharge patient saturating 94% ra, >95% 1l. . # blood pressure . during micu stay pt had repeated episodes of transient bradycardia and hypotension as well as episodes of paroxysmal hypertension into the sbp 180-200s. her hypertension responded to 5mg-10mg doses of iv labetalol. after significiant diuresis, her sbp remained stable in the 150-160s. on the floor, bp ran consistently high. patient was started on metoprolol and amlodipine. these medications were gradually uptitrated and at time of discharge pressures were better controlled on metoprolol 50mg tid, amlopidine 10mg qd. she was transitioned to toprol xl 150mg daily at the time of discharge. . # nutrition . patient underwent severeal video swallowing evaluation due to concern for silent aspiration. in the micu, several methods of nutrition employed: ng tube feeds as well as ppn. on transfer to floor patient on ng tube feeds. repeat speech and swallow on demonstrated improved oral and pharyngeal swallow with continued swallow delay, premature spillover and reduced base of tongue retraction. patient continued to aspirate thin liquids silently, but speech deemed it safe to initiate a po diet of nectar thick liquids and moist, ground solids with the aspiration precautions documented below. it is important to note aspiration is silent, and she will need continued speech therapy follow up with likely repeat video swallow before advancing her diet. # delirium . in the micu observed waxing and mental status worse at night and with spikes in fever. symptoms improved with zyprexa at night. the pt became more alert following extubation on , however, she had some disorientation. she received several doses of seroquel, which was discontinued when the patient became neutropenic, as it can be a potential cause of leukopenia. over the course of the next few days, her became more alert and interactive. by time of transfer from micu to floor on , she was fully oriented and had a good understanding of the medical plan. on the floor, patients mentation continued to improve. at time of discharge patient mental status was clear and coherent. . # elbow mass . mass noted on right elbow. derm consulted; felt to be consistent with lipoma. . # uti: she developed low grade fevers on to 100.4, prompting urinalysis, which demonstrated uti. she will complete a 10 day course of ciprofloxacin 500mg to end . medications on admission: none discharge medications: . 1. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 2. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 3. daptomycin 500 mg recon soln sig: six hundred (600) recon soln intravenous q24h (every 24 hours). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever/pain. 6. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 7. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 8. outpatient lab work please check weekly cbc with differential, bun/cr, lfts, ck, esr/crp . all laboratory results should be faxed to infectious disease r.ns. at ( 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for anxiety. 12. oxygen at time of discharge patient requires 1l nasal cannula for comfort. discharge disposition: extended care facility: northeast - discharge diagnosis: primary methicillin sensitive staph aureus bacteremia secondary hypertension anemia discharge condition: mental status: clear and coherent discharge instructions: dear ms it was a pleasure taking care of you. . you were initially admitted to due to symptoms of back pain. upon imaging it was found that you had several abscesses throughout your spine as well as in your right knee. you underwent several surgeries to evacuate these infection and you were also started on antibiotics. your antibiotic regimen was altered several times due to significant side effects. you experienced a rash after nafcillin, and vancomyocin was thought to contribute to low cell counts. you were placed on daptomycin without side effect for a planned 8week course. a picc line was placed prior to discharge to faciliate antibiotic administration as an outpatient. you will receive repeat imaging after completion of your antibiotic therapy for interval evaluation of infection. . unfortunately, side effects from various medications prolonged your hospital course. it was thought that a combination of vancomycin and lasix contributed to decreased white blood cells (wbc). while your wbc counts were low you were placed on broad spectrum antibiotics to protect you from infection. we discontinued the medications we felt responsible for declining counts (lasix and vancomycin) and also administered a medication called neupogen to increase wbc production. after several days of neupogen treatment your white cell counts increased and stabilized. neupogen as well as broad spectrum antibiotics were discontinued prior to discharge. . we also found your blood pressures to be elevated at times during your hospitalization. you were started on medications, metoprolol and amlodipine, to better control your blood pressure. . regarding nutrition, after extubation you were noted to have difficultly swallowing. speech and swallow was consulted and after several attempts you completed and passed your evaluation. after completion, you were started on a thickened nectar liquid regimen and a soft, ground solid diet. you will need repeat speech and swallow evaluation at rehab. . changes to your medications. on arrival to the hospital you were no prescription medications. . medications we started . --to treat your infection we started daptomycin 600mg iv q24 (start date: , stop date: (total 8 weeks)) . --to treat pain we started: 1. fentanyl 25 mcg/hr patch, which can be reapplied every 72 hr; 2. two lidocaine 5 %(700 mg/patch) adhesive patchs, apply each adhesive patch daily to back 3. acetaminophen 325 mg tablet; you can take 1-2 tablets by mouth every 6 hours. . --to treat your high blood pressure we started: 1. amlodipine 10mg daily; you will take two 5mg tablets daily 2. metoprolol succinate (toprol xl) 150mg tablet daily . -- to prevent blood clot formation while you heal and are relatively limited in your movement you will continue to receive: heparin (porcine) 5,000 unit/ml solution injections three times a day . --to help treat your anxiety we started: 1. lorazepam 0.5 mg tablet, you can take one 0.5 tablet by mouth at at bedtime as needed for anxiety. . you will need outpatient lab work which your facility can obtain and fax to clinic . new allergies: lasix - contraindication - neutropenia nafcillin - contraindication - rash vancomycin (relative contraindication) - neutropenia followup instructions: department: infectious disease when: friday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart insertion of endotracheal tube fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances thoracentesis percutaneous abdominal drainage arterial catheterization arterial catheterization atrial cardioversion other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal 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 synovectomy, knee other arthrotomy, knee diagnoses: anemia, unspecified unspecified pleural effusion urinary tract infection, site not specified acute kidney failure, unspecified atrial fibrillation lipoma of other specified sites acute respiratory failure other specified cardiac dysrhythmias hypotension, unspecified bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site dermatitis due to drugs and medicines taken internally other encephalopathy pulmonary congestion and hypostasis hyperosmolality and/or hypernatremia intraspinal abscess other specified antibiotics causing adverse effects in therapeutic use delirium due to conditions classified elsewhere neutropenia, unspecified other specified retention of urine benign essential hypertension other diuretics causing adverse effects in therapeutic use psoas muscle abscess tachypnea pyogenic arthritis, lower leg penicillins causing adverse effects in therapeutic use fever presenting with conditions classified elsewhere 

Answer: The patient is high likely exposed to