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: headache, nausea and vomiting after fall. major surgical or invasive procedure: central line placement dobhoff placement x3 history of present illness: 68 year old male with past medical history of alcohol abuse (quit 2 months ago), hypertension, depression, spinal stenosis and ?chf who was admitted to neurosurgery from an osh on after falling down stair steps. patient had yelled out while falling and woke up when his wife came to him. did lose consciousness, however, and was found to have subdural and subarachnoid hemorrhages on ct head at osh. the patient initially complained of headache at the osh and upon arrival to . he has a history of imbalance/vertigo and essential tremor being worked up by neurology at the osh as an outpatient. . neurosurgery felt the hemorrhages were not operable so the patient was managed medically with mannitol in the ticu. his hospital course has been complicated by increasing cerebral edema on serial ct scans although the most recent ct scan () was stable. on admission and per ticu notes, he had been able to answer questions initially but became intermittently agitated and lethargic as his hospital course progressed. over the last weekend of discharge he was responsive to light touch but has been non verbal for at least the last 10 days of his admission. he did have a few episodes of increased right shoulder twitching which resolved with lorazepam 0.5mg x1-2 (ordered by neurosurgery after evaluating the patient). the patient also developed fevers and leukocytosis during his hospital stay. neurosurgery did not feel that it was secondary to the intracerebral bleed. one blood culture of five sets subsequently grew out coagulase negative staph. infectious disease was consulted and the patient started on vancomycin evening. there is question as to whether the blood culture x1 was due to contamination vs. a true infection. his left subclavian appears clean and tte did not show any vegetations (although not ordered specifically to evaluate for endocarditis). patient also had some hypernatremia and intermittent tachypnea. abg revealed respiratory alkalosis. hypernatremia improved with adjustment of free water boluses. echo showed mild impairment in systolic function and basal hypokinesis, so he was intermittently given lasix. . ros: remains unable to obtain. also had right shoulder twitching concerning for possible seizure activity. past medical history: * congestive heart failure, ?secondary to cardiomyopathy (ef 55% from tte on ; previous tte at osh w/ ef 45% in ) * hypertension * depression * history of alcohol abuse, quit 2 months prior to admission * spinal stenosis * recent hospitalization for pneumonia in at osh social history: married, lives with wife in , ma. was previously functional. former alcohol abuse, quit two months ago. family history: noncontributory physical exam: upon transfer to for neurosurgical evaluation: o: t: 99 bp: 162/74 hr: 76 r 18 o2sats 99% gen: wd/wn, comfortable, nad. heent: pupils: 3 to 2 bilateral eoms intact neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch, propioception, pinprick and vibration bilaterally. toes downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin . exam upon transfer to internal medicine: tm=99.3 tc=98.9 bp=127/51 (127-158/51-60) hr=59 (58-67) rr20 (20-28) o2=98-100%ra general: non-responsive, older man. opens eyes once to loud verbal stimuli but otherwise does not follow commands. rapid shallow breathing. heent: pupils round and reactive to light, left pupil more dilated than right. dobhoff in place. moist mucus membranes with face mask/humidified air in place. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, gallops, rubs; left subclavian in place - clean, dry and intact with mild sanguinous drainage, no purulence or erythema lungs: ctab anteriorly, no wheezing/rhonchi/rales, tachypneic abdomen: +bowel sounds, soft, non-tender/non-distended, overweight. no palpable hepatosplenomegaly extremities: no cyanosis, ecchymosis, trace bilateral lower extremity edema skin: warm, soft and supple. neuro: minimally responsive to loud verbal and noxious stimuli. toes upgoing in bilateral lower extremities . exam upon discharge: tm=98.1 146/61 77 18 100ra general: opens eyes and reacts to gentle touch, occasionally to verbal stimuli. heent: pupils round and reactive to light, left pupil more dilated than right. dobhoff in place. moist mucus membranes with face mask/humidified air in place. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, gallops, rubslungs: ctab anteriorly, no wheezing/rhonchi/rales, tachypneic abdomen: +bowel sounds, soft, non-tender/non-distended, overweight. no palpable hepatosplenomegaly extremities: no cyanosis, ecchymosis, 1+ bilateral lower extremity edema neuro: as in general, mildy responsive to stimulus. pertinent results: echo: suboptimal image quality. the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction suggested with basal inferior hypokinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no valvular aortic stenosis. the increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. moderate (2+) aortic regurgitation is suggested. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . head ct at osh (): at the outside hospital he had a ct of his head that showed bilateral contusions, subarachnoid, epidural. there was no shift. neck ct was negative. . head ct upon admission (): increased size of left frontal/temporal hemorrhagic contusions with surrounding edema and local mass effect, but no midline shift. 5mm right lateral convex sdh, more apparent than on prior study. increased sah with more blood in the ambient cisterns stable 2x1cm left temporal tip epidural hematoma. . head ct: impression: 1. progression of intraparenchymal hemorrhages in the right frontal and temporal lobes. stable left vertex intraparenchymal hemorrhage. there is local right-sided mass effect, but no midline shift 2. new right convexity and tentorial subdural hematoma. 3. increased subarachnoid blood, particularly within the ambient cisterns. 4. stable left temporal tip epidural hematoma. 5. equivocal left sphenoid nondisplaced fracture. 1. stable appearance of multiple foci of previously seen hemorrhage. . head ct: impression: 1. overall stable appearance of a large right temporoparietal hemorrhage with the peripheral zone of edema. minimal increased mass effect as compared to 10 hours prior, now with a 3 mm leftward midline shift. fluid level noted within is unchanged and may relate to ongoing hemorrhage/coagulopathy/anaemia. close follow up as clinically indicated if no intervention is contemplated. 2. stable left temporal tip extra- axial hematoma, diffuse subarachnoid hemorrhage, and left frontal vertex hemorrhage. no new focal hemorrhage. 3. hypodensity within the mid brain stem is again appreciated, possibly artifactual. clinical correlation and continued followup/mr (if not ci) is recommended. . head ct: impression: 1. expected evolution of right temporoparietal with fluid level, right frontal and left frontal intraparenchymal hemorrhages. given the presence of fluid level in the right temporal hemorrhage on priro studies, which may relate to ongoing hemorrhage, coagulopathy, etc, consider close follow up if no intervention is contemplated. 2. surrounding edema and mass effect, and midline shift are stable since the prior study. 3. multiple scattered foci of subarachnoid hemorrhage, and small bilateral subdural hematomas, unchanged. . head ct: impression: new, tiny left temporal subdural hemorrhage with no significant mass effect or shift of normally midline structures. otherwise, no significant change in the previously visualized parenchymal, subarachnoid, subdural, or intraventricular hemorrhages. . head ct: impression: unchanged appearance of the bilateral intraparenchymal, subarachnoid, right subdural, and left temporal epidural hemorrhages with slight increase in the effacement of the right occipital lateral ventricle and with unchanged shift of midline structures. otherwise, no significant interval change since the prior study. . head ct: there is no significant interval change. there is large frontoparietal intraparenchymal hemorrhage stable in size with extension into the right temporal lobe as seen on prior study. there is associated extensive edema and stable mass effect on the right lateral ventricle. there is a stable leftward shift of midline structures, measuring 3 mm. there are bilateral stable in size hypoattenuating extra-axial subdural fluid collections. there is a small stable right posterior hyperattenuating extra-axial fluid collection consistent with stable subdural hematoma. there are bilateral foci of subarachnoid hemorrhage, unchanged. there is no area of new interval acute hemorrhage. there is no evidence of fracture. impression: 1. no significant interval change. 2. stable right-sided large intraparenchymal hemorrhage, stable 3 mm leftward shift of midline structures. stable mass effect on the right lateral ventricle. 3. stable bilateral subarachnoid and subdural collections. 4. no new interval hemorrhage. . eeg: impression: this is an abnormal video eeg study because of continuous focal slowing and frequent epileptiform discharges over the right hemisphere, maximal in frontal parasagittal region. these findings are indicative of a potentially epileptogenic focal structural lesion in this region. there was voltage attenuation on the left, which could be secondary either to left cortical injury or to fluid between brain and electrodes (e.g. subdural or subgaleal fluid collection). there was a slow posterior dominant rhythm and moderate diffuse background slowing consistent with a moderate encephalopathy. there were no electrographic seizures. . eeg:impression: this is an abnormal video eeg study because of continuous focal slowing and frequent epileptiform discharges over the right hemisphere, maximal in the right frontal parasagittal region. these findings are indicative of a potentially epileptogenic focal structural lesion in this region. mild voltage attenuation on the left could be secondary either to left cortical injury or to fluid between brain and electrodes. there was a slow posterior dominant rhythm and moderate diffuse background slowing consistent with a moderate encephalopathy. there were no electrographic seizures. compared to the prior day's eeg recording, this eeg is unchanged. . eeg: continuous eeg: showed a very low voltage slow pattern in all areas, similar to that from the few days before. over the day, the voltage remained somewhat lower than on previous days' recordings. there were no areas of prominent focal change, and there were no epileptiform features. spike detection programs: showed some generalized sharp activity suggestive of arousal. this was infrequent and not epileptiform in appearance. there were no definite spike or sharp and slow wave discharges. seizure detection programs: there was a single entry in this file. it showed no electrographic seizure. pushbutton activations: there were none. sleep: no normal waking or sleeping patterns were evident. cardiac monitor: showed a generally regular rhythm. impression: this telemetry captured no pushbutton activations. the eeg showed a very slow and low voltage record throughout, indicative of a severe encephalopathy. there were no prominent focal changes, and there were no epileptiform features or electrographic seizures. . cxr (): portable in comparison with study of , there are substantially lower lung volumes. mild atelectatic changes are seen at the bases, but there is no definite acute pneumonia or vascular congestion. the dobbhoff tube remains in place, though the tip is below the level of the image. . cxr (): (pa and lateral the examination is limited by low lung volumes. a feeding tube and left subclavian central venous line are appropriately postitioned. there is no definite focal consolidation, pneumothorax, or pleural effusion. there is linear atelectasis in the lingula and a small amount of retrocardiac atelectasis. . cxr (): feeding tube with a wire stylet in place loops in the upper stomach and ends in the midesophagus. mild cardiomegaly is unchanged. lungs are low in volume but clear. no pleural abnormality, pneumothorax, or significant pleural effusion. left subclavian line ends in the upper svc. . microbiology: 6:39 pm blood culture source: line-aline. blood culture, routine (preliminary): staphylococcus, coagulase negative clindamycin-----------<=0.25 s erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- 4 r oxacillin-------------<=0.25 s tetracycline---------- <=1 s vancomycin------------ <=0.5 s . blood culture, routine (final ): staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. anaerobic bottle gram stain (final ): gram positive cocci in clusters. reported by phone to on @ 950 pm. . hematology cbc wbc rbc hgb hct mcv mch mchc rdw plt ct 05:00 9.1 3.65* 11.9* 35.1* 96 32.5* 33.8 17.5* 150 05:30 13.3* 4.12* 13.7* 39.3* 95 33.2* 34.9 17.4* 238 added diff 10;21am differential neuts bands lymphs monos eos baso atyps metas 05:30 68.9 19.9 7.5 3.3 0.3 added diff 10;21am basic coagulation (pt, ptt, plt, inr) plt ct 05:00 150 05:30 238 . chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:00 941 23* 0.8 130* 4.52 104 21* 10 moderately hemolyzed specimen 05:30 871 23* 0.7 133 4.0 103 24 10 . chemistry totprot albumin globuln calcium phos mg uricacd iron 05:00 8.1* 3.3 1.81 moderately hemolyzed specimen 05:30 8.7 2.8 1.8 brief hospital course: mr. was admitted to the icu for close monitoring after a closed head injury. . upon comparing his ct of the head done at the outside facility compared to the ct done here upon arrival to we noted considerable evolution of his contusions. he was started on hypertonic saline and mannitol to control intracranial edema. . on the mornig after his admission his clinical exam declined with him being very agitated with difficulty following commands and no comprehensible speech. . he was placed on twenty four hour eeg monitoring to rule out seizures as the underlying cause of his altered mental status. eeg showed some spikes in the right hemeisphere but no clear seizure activity. pt was febrile to 101.2 therefore he was pan cultured. . he remained in the icu for two days on a nicardipine gtt for blood pressure control with hourly neuro checks, mannitol and hypertonic saline administration. . on hospital day 4 he was transfered to the step down unit. the patient remained neurologically stable except that his left arm which was previously moving slightly, stopped moving. a head ct was performed which was negative for change. the patient was also persistently febrile and the blood cultures that were previously drawn started to grow gram positive cocci. id consultation was requested. new blood cultures were drawn and he was started on vancomycin. . on the patient continued to be febrile and not move his left upper extremity. another head ct was performed which was also stable. he continued vancomycin per id. overnight patient was bladder scanned for 1 l of urine and a foley was placed. on , patient was seen to have a worsening exam, rue spontaneous, but no movement in other extremities to noxious stimuli. he was tachypnic and medicine was consulted. a repeat head ct and cxr were ordered. . # subdural hematoma/subarachnoid hemorrhage: unfortunate situation of previously functional man s/p fall with worsening mental status likely in setting of ongoing cerebral edema and bleed. concern for onset of seizures upon initial transfer from neurosurgery to medicine given twitching shoulder and persistent non-responsiveness. previous eegs had not shown seizure activity. repeat 24-48 hour eegs also did not show seizure activity so the patient's keppra was tapered off. he was described to be encephalopathic on eeg so an ammonia level was sent and came back at 61 (upper limits of normal 60). although the patient has known history of alcohol abuse with likely liver cirrhosis and moderate ascites on ct abdomen, he was not felt to be experiencing hepatic encephalopathy. no lactulose or rifaximin was started. neurosurgery continued to follow the patient while on the medicine service. serial ct head showed interval stability of his brain bleeds. the patient was closely monitored neurologically and nutrition supplied by dobhoff. the patient had initially been agitated, requiring seroquel for agitation but by transfer to medicine, was minimally responsive to noxious stimuli so seroquel was held. by day of discharge, the patient was more interactive and alert, would open eyes/turn his head/make verbal noises to verbal stimuli although still unable to follow commands. did demonstrate ability to move right arm and leg, although not the left side. - continue tubefeeds as prescribed via dobhoff. require intermittent restraints to prevent him from pulling dobhoff out. he receives his meds/nutrition all via dobhoff. - patient is to follow-up with his primary neurosurgeon who followed him during this hospital course, dr. in for evaluation of improvement. it was felt that the patient needs 3-4 weeks from time of discharge to recover and provide clearer picture of prognosis. - continue to monitor mental status, neurological checks twice daily . # fever: patient had low grade temperatures and then spiked to 101.8 on . infectious disease was consulted when one blood culture grew out coagulase negative staph. the patient was empirically treated with iv vancomycin (therapeutic levels) for six days but this was discontinued given unclar source and feeling that the blood culture had likely been a contaminant. the patient gradually developed a leukocytosis that peaked at 21. given negative blood cultures, chest xrays, urine cultures, his central line was pulled and the tip cultured, which also was negative. his foley catheter was changed without improvement in his symptoms. when he developed fevers to 102.6 twice daily, infectious disease was called again who recommended empiric treatment with vancomycin liquid. cdiff toxin studies negative x3. ultimately, cdiff pcr was sent and returned negative. the patient had a second blood culture grow out coagulase negative staph as well. given that this grew in an anaerobic bottle, the patient was resumed on iv vancomycin. as he continued to improved, with resolving leukocytosis and no more fevers, he was empirically treated with iv and po vancomycin. when the cdiff pcr returned negative, his vancomycin po was discontinued without issues. - continue to monitor leukocytosis and trend fever curve - continue vancomycin 750mg twice daily through . # hypertension: patient has a history of hypertension although was not taking antihypertensives prior to this admission. hypertension felt due to central dysregulation from his sdh/sah, possible ongoing discomfort as well. per neurosurgery, goal blood pressure of systolic <160 is adequate. patient has borderline bradycardia. his clonidine was initially tapered off in hopes of eliminating all sedating medications but as he became more interactive, his blood pressures became less well controlled with occasional peaks in the sbp170s. - please taper clonidine 0.2mg from twice daily down and titrate other medications upwards accordingly throughout his stay. - continue lisinopril 40mg daily - continue metoprolol three times daily - continue hydralazine prn sbp>160 . # tachypnea: in discussions with neurosurgery, this is felt likely related to his ongoing cerebral edema, bleeding; there may be a component of ongoing discomfort as well. cxr showed no acute cardiopulmonary processes and abg with respiratory alkalosis. as patient's fevers were treated with tylenol/vancomycin and his pain with morphine liquid, his tachypnea improved. as his sdh/sah stabilized, the patient's tachypnea ultimately resolved. . # sodium balance: patient had a free water deficit per calculations when initially transferred to medicine. his free water flushes were tweaked until his serum sodium was stable. - please check sodium on as patient beginning to have slight hyponatremia treated with lasix and decrease in free water flushes on day of discharge. . # foley: please remove foley and attempt voiding trial (no clear indication for presence of foley at this time). . # goals of care: in discussions with the patient's wife who is his healthcare proxy, the patient was made dnr/dni given his critical condition. the patient does have advanced directives and made it clear to his wife he did not wish to live out his days neurologically compromised or in a . . # communication: (wife, at medications on admission: wellbutrin prozac furosemide allopurinol propranolol discharge medications: 1. senna 8.6 mg tablet : 1-2 tablets po qhs:prn as needed for constipation. 2. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po daily (daily) as needed for constipation. 3. lidocaine hcl 2 % gel : one (1) appl mucous membrane prn (as needed) as needed for foley pain. 4. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic prn (as needed) as needed for dry eyes. 5. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day) as needed for oral care, thrush. 6. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 7. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day): to groin region. 8. morphine 10 mg/5 ml solution : 5-10 mg po q4h (every 4 hours) as needed for pain: hold for sedation changed from current baseline, rr<12. 9. hydralazine 25 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for prn sbp>160. 10. lisinopril 20 mg tablet : two (2) tablet po daily (daily): hold for sbp<100. 11. metoprolol tartrate 25 mg tablet : one (1) tablet po tid (3 times a day): hold for sbp<100, hr<55. 12. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 13. folic acid 1 mg tablet : one (1) tablet po daily (daily). 14. cyanocobalamin (vitamin b-12) 100 mcg tablet : 0.5 tablet po daily (daily). 15. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day): per pharmacy, please crush tablet to powder first, then dissolve in water, prior to putting through dobhoff . 16. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 17. clonidine 0.2 mg tablet : one (1) tablet po bid (2 times a day). 18. vancomycin 750 mg recon soln : seven y (750) mg intravenous twice a day for 2 days: last dose on . discharge disposition: extended care facility: - discharge diagnosis: primary: subdural hematoma, subarachnoid hemorrhage, presumed cdiff infection, possible coagulase-negative staphylococcus infection secondary: systolic congestive heart failure, hypertension, history of alcohol abuse, depression, spinal stenosis discharge condition: mental status: unable to assess level of consciousness: alert and interactive to verbal stimuli, will turn head and open eyes but does not follow commands. moves right arm and leg, but not purposeful. activity status: bedbound. discharge instructions: dear mr. , . it was a pleasure taking care of you during your admission to . you were admitted after a fall on a few stair steps and was found to have bleeding in the various layers in and around your brain. you were closely monitored in the icu and given mannitol and blood pressure medications to decrease swelling/bleeding into your brain, which can be dangerous. neurosurgery continued to follow you closely during your hospitalization until the bleeding in your brain stabilized. eeg monitoring showed you were not having seizures from the injury to your brain. . you developed fevers and your blood tests suggested you had an infection. you were empirically treated for clostridium difficile, an infection of your intestines that can cause diarrhea; the exact test for this infection eventually came back negative so the oral antibiotic was stopped. you were also treated for an infection in your blood stream. you responded well and became more interactive and comfortable towards the end of your hospital stay. . you are being discharged to a long-term acute care hospital where there will be qualified nurses and physicians to help monitor your progress during this important time in the healing of your brain from your traumatic injury/fall. followup instructions: please follow-up with your neurosurgeon, dr. , who will evaluate your progress after your traumatic brain injury. you will obtain a ct scan of your head before the appointment. department: radiology when: thursday at 10:00 am with: cat scan building: cc clinical center campus: west best parking: garage department: neurosurgery when: thursday at 11:00 am with: , md building: lm campus: west best parking: garage procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus diagnoses: other primary cardiomyopathies congestive heart failure, unspecified unspecified essential hypertension alcoholic cirrhosis of liver other and unspecified alcohol dependence, in remission depressive disorder, not elsewhere classified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure alkalosis bacteremia accidental fall on or from other stairs or steps intestinal infection due to clostridium difficile cerebral edema other ascites methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site do not resuscitate status encephalopathy, unspecified hyperosmolality and/or hypernatremia other and unspecified infection due to central venous catheter acute on chronic systolic heart failure spinal stenosis, unspecified region dizziness and giddiness essential and other specified forms of tremor cortex (cerebral) contusion without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level 

Answer: The patient is high likely exposed to