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: morphine attending: chief complaint: mrsa sepsis major surgical or invasive procedure: trans-esophageal echocardiogram dialysis catheter placement history of present illness: 79yom admitted to on for constipation. this resolved with aggressive bowel regimen. on , became hypotensive to bp in 70s, with unresponsiveness. wbc spiked to 27, fever to 100.1, with ag acidosis. blood cultures were positive for mrsa. pt was given vancomycin, dosed by level. he was placed on dopamine and fluid resuscitated; dopamine was switched to levophed secondary to tachycardia; pressors were discontinued on am of transfer. . pt had progressively worsening renal function, as well, with baseline bun almost 100 and cr 2.6-2.7. this was thought to be due to over-diuresis, perhaps with a component of sepsis. pt could not be dialyzed due to low maps, and was therefore transferred here for cvvh. at osh, pt also received ffp for elevated inr and ddavp for bleeding at site of r ij. . pt denies chest pressure, sob, or abdominal pain. no dysuria. no orthopnea, pnd, no lightheadedness/dizziness. no headache. + bm in the last 2 days. no changes in color of stool, no brbpr. overall feels fatigued, attributes this to lack of sleep. denies fevers, chills, or sweats. past medical history: cad s/p cabg, multi pci ischemic cardiomyopathy(ef<20%) diabetes, on insulin. chronic atrial fibrillation, on coumadin. status post biv pacer/icd chronic renal insufficiency (cr 2.7-2.9)complicated by acidosis on sod bicarb and hyperkalemia requiring kayexalate treatments as an outpatient. gout on allopurinol anemia on procrit social history: + tob, 15 pack-years, quit ; smoked cigars intermittently in 70s. occasional etoh, no ivdu. lives at home with his wife and disabled son in . family history: mother - cad ? age, dm 2 brother - epilepsy son - ischemic cardiomyopathy / congestive heart failure . allergies: no known drug allergies. questionable allergy to morphine (sbp dropped on morphine administration). physical exam: vs: 96.1 89/55 74 18 100% ra gen: alert, nad heent: perrl, eomi, op clear, mm somewhat dry neck: no jvd, no carotid bruits chest: aicd in place, no tenderness, erythema or swelling over pocket cv: rrr, nl s1/s2, no murmurs appreciated pulm: ctab, no wheezes or crackles abd: soft, nt, mildly distended, + ecchymosis at site of heparin injection, + bs ext: + pitting edema in b le; + ecchymosis on arms bilaterally pertinent results: 07:10am blood wbc-10.3 rbc-3.06* hgb-9.4* hct-31.7* mcv-104* mch-30.9 mchc-29.8* rdw-20.9* plt ct-135* 04:00am blood wbc-12.3*# rbc-3.21* hgb-10.0* hct-30.0* mcv-93 mch-31.1 mchc-33.3 rdw-19.1* plt ct-68*# 04:10am blood neuts-79.6* lymphs-15.0* monos-3.4 eos-1.3 baso-0.6 04:10am blood hypochr-3+ anisocy-2+ poiklo-1+ macrocy-3+ 07:10am blood plt smr-low plt ct-135* lplt-8 07:10am blood pt-16.5* ptt-37.0* inr(pt)-1.9 02:00pm blood esr-10 07:10am blood glucose-103 urean-120* creat-6.4*# na-150* k-7.2* cl-113* hco3-15* angap-29* 04:00am blood glucose-102 urean-125* creat-2.8* na-134 k-4.0 cl-98 hco3-21* angap-19 01:10pm blood alt-9 ast-20 ld(ldh)-289* alkphos-136* totbili-2.4* 07:10am blood calcium-8.8 phos-10.5*# mg-2.8* 01:30am blood calcium-9.7 phos-6.6* mg-2.6 06:55am blood calcium-9.5 phos-6.2* mg-2.6 04:10am blood calcium-9.9 phos-5.5* mg-2.3 07:45am blood calcium-9.4 phos-4.3 mg-2.3 03:40am blood calcium-9.4 phos-4.0 mg-2.7* 10:45pm blood cortsol-44.4* 10:15pm blood cortsol-43.3* 03:15pm blood cortsol-28.6* 02:00pm blood crp-112.9* 04:10am blood vanco-28.6* 03:00pm blood vanco-16.6* 10:20pm blood type-art rates-/24 fio2-99 po2-236* pco2-29* ph-7.46* calhco3-21 base xs--1 aado2-458 req o2-76 intubat-not intuba 10:20pm blood lactate-2.1* 10:20pm blood freeca-1.17 . tte/chest echo : focused study on pacing wires. the inferior vena cava is dilated (>2.5 cm) c/w elevated ra pressure. catheters/pacing wires are seen in the ra and raa. no discrete vegetation is identified (best excluded by tee). left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated with severe global hypokinesis. the right ventricular cavity is dilated. there is severe global right ventricular free wall hypokinesis. the aortic valve leaflets are moderately thickened. the mitral valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , the catheters appear similar. 1. no abscess as clinically questioned. 2. hypoechoic mass present just deep to the left pectoralis muscle. this exam was not done in the radiologic department, it done by the patient's bedside. further evaluation is recommended with scanning by the radiologist. it is unclear if this represents a solid mass or entity such as a hematoma. . cxr : 1. persistent pulmonary edema. 2. mild cardiomegaly with small bilateral pleural effusions. 3. biventricular pacer device in good position. . ct abd/pelvis : 1. study limited due to lack of iv contrast. no source identified for the patient's mrsa bacteremia by noncontrast ct scan. 2. small bilateral pleural effusions, left side greater than right. . ct sinus : acute right maxillary sinusitis. . upper extr u/s : no deep venous thrombosis in right or left internal jugular, subclavian, axillary, basilic, brachial or cephalic veins. . bone scan : in conjunction with the indium wbc scan performed today, there is no evidence of osteomyelitis within the spine. increased activity in the clavicle on the wbc scan is not seen on the bone scan. this is unlikely to represent infection, and may represent marrow changes. . cxr : new parenchymal abnormality in the lower lungs has a similar pattern to that on which cleared by , suggesting a combination of mild pulmonary edema and atelectasis accompanied by increasing small bilateral pleural effusions. moderate cardiomegaly is stable. intended right atrial and left ventricular pacer and right ventricular pacer defibrillator leads are continuous from the left pectoral power pack and project over their expected courses. a right ventricular pacer lead fragment ends in the right chest wall. right pic catheter has been removed. . wbc scan : 1. no abnormal tracer activity within the spine. 2. increased tracer activity in the medial left clavicle. this may suggest infection or inflammation. the patient is to undergo tc-99 bone scan and correlation with the bone scan is recommened. 3. increased activity in the region of the right maxilla. no clear sinusitis is seen on the panorex film. if there is clinical concern for a periodontal process, a ct of the sinuses is recommened with imaging through the mandible. . echo : mildly thickened mitral and tricuspid valves without discrete vegetation seen. moderate to severe tricuspid regurgitation and mild to moderate mitral regurgitation. moderately thickened and calcified aortic valve with mild aortic regurgitation but no discrete vegetation. severely depressed left and right ventricular function. . cxr : left lower lobe pneumonia. . ct neck : severe atherosclerotic disease. no destructive processes of the osseous structures. no paraspinal soft tissue masses or abscess. . cxr : right ij line in satisfactory position, no other significant change. stable cardiomegaly. brief hospital course: a/p: 79y/o m with dm2 c/b esrd with mrsa sepsis . 1. mrsa bacteremia - patient transferred from osh w/ mrsa bacteremia (8/31 mrsa, 9/1 mrsa, 9/2 mrsa, mrsa). was transiently on pressors for hypotension but was off of these prior to transfer to . unclear source of infection - no evidence of pna by cxr or symptoms, no open skin lesions. tte performed at osh with no evidence of vegetations, but tee planned to r/o endocarditis. patient was to have tee on but was hypotensive to 90's/40's and procedure postponed. also, patient was complaining of neck pain and a ct of neck was done to look for epidural abscess/osteomyelitis, etc (no contrast used due to renal function and unable to get mri due to aicd). has been on vancomycin since at osh. vancomycin dosing by daily levels, with goal between 15-20. serial blood cultures consisently grew mrsa, which were all sensitive to vancomycin. tee performed on . during procedure, pt became hypotensive (60-70's) and was given dopamine and 500cc fluid. pt remained assymptomatic during the event. tee was able to performed and it showed no changes. no signs of thrombosis or vegetative growth. moderate to severe tr, mild to moderate mr. vanco was continued. a picc line was placed on . bcx sent on returned positive for staph infection. cxr was obtained to r/o aspiration pna. it showed a lll pna. initated levofloxacin x 7 days. on , pt began c/o sob. nebulizers were initated. pt has been coughing up sputum. however, he was able to swallow and eat without any problems. this was once speech/swallow evaluated him and set him on a ground diet. pt continued on iv vancomycin, with routine trough measurements. bcxs continued to be drawn and showed continued growth. id consulted and determined that vanco is appropriate treatment (surveillance cultures have all demonstrated sensitivity to vanco). an mri of the spine was warranted, however, unable to be performed due to aicd. a ct can not be performed due to patients renal issues. a wbc tagged scan was ordered to assess for any sources of possible infection. this test, and a bone scan, did not reveal a source of infection. a right maxillary sinusitis was noted and was confirmed by sinus ct, however, id thought this was a highly unlikely source of mrsa. vancomycin was continued however cx remained + for mrsa. although the serial blood cultures indicated that the mrsa was vanco sensitive, the family requested "other options" for antibiotics, which resulted in a switch to daptomycin/doxycycline/rifampin and d/c of the vancomycin. by the time this regimen was started, the patient was obtunded and anuric, and id recommended stopping the rifampin to avoid adverse side effects of overdose. the patient was made dnr/dni, but at the family's request, the abx were continued until the patient expired on . . as best as could be determined from the studies obtained, there was no other source of persistent infection other than the pacer wires. dr. (from ep), who had originally placed the wires, evaluated the patient for potential wire removal, and after discussion with the family and patient, it was not considered feasible and carried an extremely high mortality with no guarantee of clinical improvement even if the patient tolerated the surgery. . 2. hypotension - mrsa growing out of blood cultures thought to be the precipitator of hypotension. however, patient was also intravascularly dry after diuresis at osh. cortisol and stim test performed with no evidence for adrenal insufficiency (patient was treated with hydrocortisone and fludrocortisone and d/c'd once results of cosynotropin stim test back on ). while patient is total body fluid overloaded, his ecv is down, likely in the setting of decreased cardiac output (ef 10-20%) and infections. on evening and through night he became hypotensive into 90's and was given gentle fluids and maintained maps >60. no need for pressors during icu stay. as of , no ivf given on the floor. bp remained stable betwen 90-100. monitored bp when lasix was reinitiated, and pt tolerated it well. on , pt was hypotensive at 80/d. concern over that pt becomes dazed in mid-conversation. adjusted his insulin regimen as this may contributing. in order to maintain bp for effective diuresis, pt. was started on a dopamine drip (administered on a cardiology unit with continuous telemetry monitoring). the patient's sbp was stable in the 100-110 range during the time he received dopamine, and he was able to tolerate iv lasix, to which he diuresed nicely. his cr was monitored throughout this period to prevent over-diuresis. dopamine was stopped when the patient appeared euvolemic, and his bp remained stable for several days, but the patient gradually went in to renal failure and became anuric. dialysis was considered, and a dialysis catheter was inserted by ir, but at this time, the patient was agitated with tremors and hemodynamically unstable, and the recommendation from the renal service was that the patient would likely be unable to tolerate dialysis. at this point, the patient was dnr/dni, and iv fluids were stopped and the patient remained anuric until he expired. . 3. acute on chronic renal failure - baseline cr 2.6-2.7, but admitted with cr in low 3's. patient was transferred to in case of need for cvvh, but renal was consulted and found no indication for hd. patient was total body fluid overloaded (slightly), but not initially to the point of needing dialysis. as described above, following dopamine/lasix diuresis, the patient gradually went into acute renal failure and was not able to undergo dialysis. . 4. systolic congestive heart failure - patient with significant systolic chf (ef 10-20% on recent echo), with no evidence of acute decompensation on exam. pt. consistently sat'ed well. patient's lasix and bb were held due to hypotension while in icu. pt remained off lasix and bb until after the tee. lasix continued to be withheld due to pressure drop during the tee. on , lasix increased at slow rate and asa reinstated. vs remained stable. on , pt was on 20mg po daily and was changed to 10mgiv on . change due to increasing edema of le. cardiac function remained poor throughout hospitalization. . 5. coronary artery disease - patient has had cabg and cath in 03 and 04, respectively. no symptoms of angina during hospitalization. no evidence of ischemia on ecg, though pt's pacer makes interpretation of ecg limited. plavix was continued, but this should be addressed with cardiology as it appears he has been on it for >9 months. asa held in setting of thrombocytopenia and likely uremic plts. bb held in setting of hypotension. on , it was decided that asa would be reinitiated at low dose, and plavix was continued. . 6. atrial fibrillation - pt. was well rate-controlled. while in hospital, coumadin was held in setting of oozing from r ij catheter. pt. remained in nsr until he expired. . 7. thrombocytopenia - unclear etiology (new since this admission). platelets that are present likely dysfunctional as bun > 100. hit ab was negative. avoided heparin while in the hospital. platelet level continued to steadily increase until pt. expired. . 8. anemia - chronic, due to underlying iron and b12 deficiency. also chronic kidney disease likely an etiology of anemia. on epogen 3x/week. blood levels wer monitored as per routine. . 9) on presentation, pt has back/neck pain. concern that it was attributed to om or the bacteremia had spread to his spine. ct was performed and found to be negative for st disease or bony destruction. atherosclerosis was noted. tylenol was given to treat the pain. . 10) dm: pt was placed on 19nph at admission. on , notable decrease in blood glucose. d/c nph to asssess how pt is without it. this was due to his level running very low (32 at 600am). decided to monitor for changes. . 11) code: pt. was admitted full code. when surgical removal of the pacer wires was deemed not feasible, and when pt. became anuric and was not considered a candidate for dialysis, several family meetings resulted in a consensus that the pt. would be dnr/dni, and treated as comfort measures only. dnr/dni documentation was signed by son in presence of wife, daughter, and other son, who were all in agreement. although pt. was comfort measures only, antibiotics were continued at family's request, and ativan, valium, and dilaudid were given ad lib. the patient expired pain-free and without incident. medications on admission: aspirin 81mg po daily plavix 75mg po daily naproxen 50mg po daily epogen 10,000 units qmwf toprol xl 25mg po daily vitamin b12 100mcg po daily flovent 2 puffs iron 325mg po daily gemfibrozil 600mg po bid allopurinol 100mg every other day coumadin 3mg po qhs lasix 40mg po daily calcitriol 0.25mg po daily sevelamer 800mg po daily insulin 19 units nph in am, 3 units humalog ? nph/humalog at night discharge medications: not applicable. discharge disposition: expired discharge diagnosis: mrsa bacteremia congestive heart failure acute renal failure discharge condition: expired. discharge instructions: not applicable. followup instructions: not applicable. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart venous catheterization for renal dialysis diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified severe sepsis atrial fibrillation infection with microorganisms resistant to penicillins aortocoronary bypass status methicillin susceptible staphylococcus aureus septicemia systolic heart failure, unspecified other specified forms of chronic ischemic heart disease automatic implantable cardiac defibrillator in situ infection and inflammatory reaction due to cardiac device, implant, and graft 

Answer: The patient is high likely exposed to