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: transfer from osh for sepsis major surgical or invasive procedure: 1. : ct guided aspiration of t5-6 paraspinal fluid collection. 2. : thoracentesis. history of present illness: mrs is a 49 yo woman with a medical history notable only for hypertension who was in her usual state of good health until 10 d prior to admission to an osh when she started having fevers, nausea, and back pain. she treated herself with motrin and continued going to work until 3 d pta. on , she was brought home early by coworkers b/c she was not feeling well and by 6:00 pm that night she was becoming increasingly confused and complained of visual symptoms ("unable to see anything, lights flashing") and her family called ems. at the osh she was unable to follow commands, became combative, and was given ativan. initial labs at the osh included wbc 17.3, hct 41, plt 112, bun 22, creat 1.2, albumin 1.8. she had an lp, which showed wbc 208 (82 polys, 8 lymphs, 10 monos), rbc 3, glu 49, prot 83 and an opening pressure of 18 cmh2o. a csf gram stain showed no polys, no bacteria and a negative culture. a urine culture grew mssa and blood cultures also grew mssa. an echo at the osh was of poor quality due to the patient's agitation, and showed focally thichened aortic valve, but no vegetations, valvular abnormalities, or pericardial effusions. she was initially treated with vancomycin, ceftriaxone, and acyclovir, and was transferred to for further management. past medical history: 1. htn. 2. probably had chickenpox as a child according to mother. social history: she lives with her husband and two children (aged 16 and 20) in , ma. she formerly worked as a 5th and 6th grade math teacher but for the past year has worked as a secretary for a general contractor. has had three sexual partners with no known history of sexually transmitted diseases. she has no history of blood transfusions. she states that she drinks 2-3 glasses of wine per night. no history of smoking or iv drug use. family history: 1. cad. 2. htn. 3. daughter has sz disorder. 4. no history of immunodeficiency. physical exam: vs: tm 100.3, bp 114/65 on 0.04 levophed, hr 82, rr set at 12, ac fio2 50%, tv set at 500. intubated, sedated heent: r small conjuctival hemorrhage. rrr, no mrg ctab s/nt/nd extr: no . numerous lesions over palms and soles reminiscent of endocarditis stigmata (splinter hemorrhages, lesions, osler nodules). skin: in addition to above, has several vesicular lesions diffusely over all extremities, some look herpetic/crusted. pertinent results: labs at discharge: wbc: 9.7 hematocrit: 33.0 platelet: 342 na 140 k 3.7 cl 103 co2 24 bun 8 cr 1.1 glucose 127 ca 9.4 mg 1.7 ph 5.0 alt 6 ast 13 ldh 286 alk phos 157 t bili 0.4 esr 66 microbiology: - blood cultures: no growth. urine clx: no growth. urine clx: > 100,000 yeast. urine clx: > 100,000 yeast. urine clx: 10-100,000 enterococcus (vancomycin resistant). urine clx: mixed bacterial flora consistent with contamination. , , , stool: negative for c. difficile. pleural fluid: no pmns, no organisms on gram stain, negative culture. paraspinal abscess: 1+ pmns, no organisms on gram stain, rare methicillin sensitive staph aureus. ekgs: : normal sinus rhythym. rate pr qrs qt/qtc 90 132 78 394/441.71 : normal sinus rhythym. rate pr qrs qt/qtc 87 134 82 412/456.42 studies: trans-esophageal echo: the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is a large (1cm x 3cm long) highly mobile) vegetation is seen within the left atrium attached to the base of the anterior mitral valve leaflet. the posterior mitral leaflet appears somewhat rudimentary, but without discrete vegetation. no mitral valve abscess is seen. an eccentric jet of moderate to severe (3+) mitral regurgitation is seen (posteriorly directed) originating at the base of the anterior leaflet (suggests perforation). there is no pericardial effusion. compared with the prior tee study (tape reviewed) of , the anterior mitral leaflet vegetation appears slightly larger and the posterior leaflet is less "rudimentary." the degree of mitral regurgitation has significantly increased. trans-thoracic echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is a large vegetations on the mitral valve (one on the anterior leaflet and one on the posterior leaflet). moderate (2+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. there is a very small pericardial effusion. compared with the prior study (tape reviewed) of , mitral regurgitation is now more prominent and vegetations are now more prominent. ct of abd, pelvis: 1. persistent terminal ileitis. etiology includes infectious versus inflammatory process. 2. persistent large bilateral pleural effusions with bibasilar compressive atelectasis. 3. small free fluid in the pelvis, but no evidence of abscess. trans-thoracic echo: 1. the left atrium is mildly dilated. 2. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. 3. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a large (2 x 1 cm) , mobile vegetation on the mitral valve. 4. compared with the findings of the prior study of , there has been no significant change. ct of chest, abd, pelvis: 1. interval increase in size of bilateral large pleural effusions with worsening bibasilar compressive atelectasis. diffuse ground glass opacities within the lungs are likely due to pulmonary edema. 2. ill-defined, new, nodular opacities within both upper lobes, which are non- cavitating. these are likely inflammatory or infectious in etiology. 3. interval development of ascites and marked third-spacing fluid within the subcutaneous tissues. 4. stable appearance of hypodense lesion within the left kidney, which may represent a cyst or area of scarring. 5. tiny amount of gas within the subcutaneous tissues of the left abdominal wall at the level of the umbilicus. there is no abscess noted. 6. intramural fat and wall thickening involving the terminal ileum, which appears worse in the interval. no bowel obstruction or surrounding fat stranding. these findings suggest a chronic inflammatory process involving the terminal ileum such as crohn's disease; clinical correlation is suggested. 7. bilateral enhancing paraspinal fluid collections at the t5/6 level, likely secondary to discitis. no associated osseous destruction noted. echo: 1. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). 2. there are simple atheroma in the aortic arch and descending thoracic aorta. 3. there is a large vegetation (2.5 x 0.7 cm) attached on the left atrial side to the lateral portion of the mitral annulus and the basal portion of the posterior leaflet of the mitral valve. the vegetation is mobile and prolapses into the left ventricle during diastole. no mitral valve abscess is seen. trivial mitral regurgitation is seen. mri of l-spine: no evidence of bone, disc or intraspinal abnormality to suggest infection of the lumbosacral spine. there is no lumbosacral neural impingement. mri of head: multiple foci in the right cerebellum, right splenium, and right superior cerebral cortex of signal abnormality and diffusion signal hyperintensity are consistent with areas of infarction and perhaps infection. findings may be compatible with an early infection, and septic emboli should be considered, particularly in view of the patient's staph aureus bacteremia. mri of c-spine, t-spine: findings are consistent with osteomyelitis and discitis with epidural and paraspinal infection at the t5-6 level. there are slight abnormalities in the c5-6 disc space and c5 vertebral body, though there are no clear signs of infection in this location at this time. u/s of abd: 1. normal gallbladder and bile duct. 2. coarse liver echo texture without focal lesions. ct of head: hypodense lesions, as described above, most pronounced in the right cerebellar hemisphere and right splenium of the corpus callosum. the differential diagnosis includes evolving infectious process, possibly representing hematogenous spread, infarction, and neoplasm. ct of chest, abdomen: 1. bilateral dependent areas of atelectasis/consolidation with associated small pleural effusions. the possibility of aspiration is raised given the reflux of contrast noted in the esophagus. 2. the questioned right mid thoracic paraspinal abnormality is not well assessed given the adjacent acute abnormalities and fluid. differential considerations include loculated pleural fluid versus benign cystic structures, although underlying pathology is difficult to exclude. no adjacent bony destruction is seen. 3. no evidence of abscess within the abdomen or pelvis. procedures: ct-guided aspiration of right t5/t6 paraspinal collection 1. 2 cc of purulent material aspirated from the right t5/t6 paraspinal soft tissue density in keeping with some abscess component with that area. brief hospital course: mrs. is a 49 yo woman who was transferred from osh with methicillin sensitive staph aureus bacteremia complicated by mv endocarditis, multiple septic emboli to brain, t5/6 diskitis, and disseminated zoster infection. . 1icillin sensitive staph aureus bacteremia: this was of unclear etiology as she denied any iv drug use, recent instrumentation, or recent cutaneous injuries. she was noted to have a crusted over lesion on her right foream which looked suspicious for a source but she did not recall the duration of this lesion. on admission to the icu she initially required blood pressure support with iv fluids and pressor agents. these were eventually weaned off and she was able to maintain her pressure. imaging revealed evidence of dissemination with endocarditis (mv vegetation), t5-6 osteomyelitis with a paraspinal fluid collection, and cerebral emboli. she was started on oxacillin 2 grams iv every four hours and should complete a six week course (should finish on ). she had slow clinical improvement and denied specific symptoms but had persistent fevers while on oxacillin. this was pursued with repeat imaging of the chest, abdomen, and pelvis on which revealed large bilateral pleural effusions and the continued presence of a fluid collection around t5-t6. a thoracentesis was performed on which revealed a transudative fluid. a ct guided aspiration of the paraspinal fluid collection was also performed on which revealed 1.5 cc of purulent fluid that contained rare methicillin sensitive staph aureus. a tte was done on which showed an unchanged mitral valve vegetation. her fevers declined somewhat following the drainage of her paraspinal fluid collection but she did not completely defervesce. a repeat abdominal ct was performed on to look for an occult abscess and to follow up terminal ileum thickening seen on the study. this ct revealed persistent bilateral effusions and terminal ileum thickening but no abscesses. on she was noted to have a new 2-3/6 llsb echo and a tte done on showed an increase in the size of her mv vegetation, more prominent mitral regurgitation, and a small pericardial effusion. both cardiology and ct surgery were consulted and she underwent a tee with anesthesia on to better characterize her valve and rule out an abscess. this revealed that her vegetation was more prominent and her valvular regurgitation was more prominent as well (please see results sections for more details). ct surgery would like to replace her valve surgically but would like for her to complete as long of an antibiotic course as possible before surgery is undertaken. thus she is being discharged to home on iv antibiotics with the following f/u appointments: 1. she will see dr. in ct surgery on to discuss the timing of her valve replacement. 2. she will see one her cardiologist, dr. , before her surgery to arrange for a cardiac catheterization prior to her surgery. 3. she will see dr. in the id department on to discuss the duration of her antibiotic treatment. at this appointment, the id department may also consider repeat imaging of her spine to assess if her t5-t6 osteomyelitis has resolved. 4. she will need to have dental clearance prior to her cardiac surgery. she knows this and will arrange for this near her home. 5. while on oxacillin she should have weekly blood work including a cbc, chem 7, lfts. she should also have regular ekgs to test for conduction abnormalities. ekgs done in the hospital showed no acute changes. her lab results should be faxed to , md in the infectious disease department at . 6. when available, she should have a flu shot. 2. hypertension: she came into the hospital with the diagnosis of hypertension but her toprol was initially held. as she came out of the micu her blood pressure began to rise and she was eventually re-started on toprol xl which was titrated up to 100 mg daily. at the suggestion of cardiology, she was also started on captopril for afterload reduction given her mitral regurgitation. this was titrated up to 25 mg tid and switched to lisinopril 10 daily for ease of pill taking. by the end of her hospitalization her systolic blood pressure was in the low 140s. she was discharged on toprol xl 100 daily and lisinopril 10 mg daily. her blood pressure should be followed up by her primary care physician as she will likely need further titration of her meds to attain a goal sbp in the 120s. 3. left sided weakness: she was noted to have left arm weakness (more pronounced in her deltoid and biceps) throughout her hospitalization. this was thought to be due to her right sided cerebral emboli. her strength gradually improved throughout her hospitalization with regular physical therapy. at discharge she was still generally weak below her baseline and was encouraged to maintain physical therapy as an outpatient. 4. diarrhea: she did complain of loose, non-bloody stools intermittently throughout her hospitalization. c. difficile toxin tests were negative multiple times. abdominal ct scans showed terminal ileum thickening thought to be consistent with either an infectious or inflammatory process. she denied any personal or family history of inflammatory bowel disease. by the end of her hospitalization her diarrhea had resolved somewhat. further workup of her diarrhea and ti thickening should be considered by her pcp. 5. anemia: her hematocrit on admission was 33.2. throughout her hospitalization her hematocrit was in the mid to high twenties and she required three transfusions for hct less than 25. iron studies were consistent with anemia of chronic disease. by the end of her hospitalization, her hematocrit was 33. 6. pleural effusions: she was noted to have pleural effusions on ct scan and was started on lasix 20 mg po daily on . she responded with a brisk diureses and improvement in her oxygenation. she was continued on lasix 20 po daily at discharge. this should be followed up by her pcp as she will likely not need lasix chronically. 7. vision changes: she had reportedly complained of vision changes at the outside hospital. once she was extubated she no longer complained of vision trouble and had an unremarkable vision exam. ophthalmology was consulted and found no evidence of endopthalmitis. they did note bilateral superficial hemorrhages perhaps secondary to hypertension and recommended artificial tears for comfort. she was encouraged to use artificial tears on a prn basis as an outpatient. 8. zoster: her skin exam on admission was notable for multiple herpetiform clusters of erythematous erosions across her right buttock as well as on her extremities and back. dermatology was consulted and recommended a seven day course of iv acyclovir. a dat for vzv and hsv 1 and 2 was negative but her lesions crusted over following completion of acyclovir. 9. low albumin: her albumin on admission was 1.9. the etiology of this was uncertain as her liver functions were otherwise normal and her urine only had trace protein. it was thought that her low albumin may have been due to poor nutrition. she should have a repeat albumin level drawn by her pcp once her bacteremia has resolved. 11. yeast/enterococcus in urine: she was noted to have >100,000 yeast in a urine culture drawn on . this persisted after her foley catheter was removed. she was also noted to have skin breakdown and a candidal type rash in the peri-genital area that only improved minimally with topical antifungal creams and powders. thus she was treated with a three day course of fluconazole (finished ) and her skin improved. a repeat urine culture on grew 10-100,000 enterococcus which were resistant to vancomycin. however, she was without symptoms and thus was not treated. a repeat urine culture drawn on was consistent with contamination. at discharge she had no urinary symptoms. disposition: she was discharged to home in stable condition with resources to help her continue taking iv methicillin every four hours as an outpatient. she was also encouraged to continue physical therapy as an outpatient to continue to increase her strength. she has follow up appointments with infectious disease, cardiology, and ct surgery. she will see her pcp in the near future for a blood pressure check as well as bloodwork including a cbc, chem 7, and lfts. medications on admission: toprol xl discharge medications: 1. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 2. picc care 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. 3. oxacillin sodium 2 g recon soln sig: one (1) recon soln injection q4h (every 4 hours) for 15 days. disp:*60 recon soln(s)* refills:*0* 4. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic qid (4 times a day). disp:*qs ml* refills:*2* discharge disposition: home with service facility: gentiva discharge diagnosis: primary diagnosis: 1. mssa bacteremia -mv vegetation. -t5-6 osteomyelitis and paraspinal abscess. -septic right sided cerebral emboli. secondary diagnosis: 1. hypertension. discharge condition: stable. discharge instructions: 1. you are being discharged home with services to help with your antibiotic therapy. 2. please continue to take your medications as prescribed - you will need to take iv oxacillin every four hours for a total of 6 weeks - this will finish on . 3. please continue physical therapy at home to maintain and increase your strength. 4. if you experience increasing fevers, increasing difficulty breathing, chest pain, new weakness or numbness, or other concerning symptoms, please seek medical attention. followup instructions: 1. you have an appointment with your pcp, . () on , at 10:00 am. 2. provider: , md where: lm disease phone: date/time: 9:30 3. provider: , cardiac surgery lmob 2a where: cardiac surgery lmob 2a date/time: 1:30 4. you will have an appointment with your cardiologist dr. at a later date. they will call you to arrange an appointment. if you have not heard from them by the end of the week please call to schedule an appointment. they will arrange for you to have a cardiac catheterization prior to your cardiac surgery. md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart diagnostic ultrasound of heart diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances thoracentesis transfusion of packed cells aspiration of other soft tissue injection or infusion of oxazolidinone class of antibiotics diagnoses: thrombocytopenia, unspecified anemia of other chronic disease other and unspecified noninfectious gastroenteritis and colitis unspecified pleural effusion unspecified essential hypertension acute kidney failure, unspecified severe sepsis candidiasis of other urogenital sites methicillin susceptible staphylococcus aureus septicemia acute respiratory failure pneumonitis due to inhalation of food or vomitus methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site septic shock acute and subacute bacterial endocarditis intraspinal abscess acute osteomyelitis, other specified sites other and unspecified alcohol dependence, unspecified other and unspecified disc disorder, thoracic region alcohol withdrawal late effects of cerebrovascular disease, monoplegia of upper limb affecting unspecified side herpes zoster without mention of complication 

Answer: The patient is high likely exposed to