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: aspirin / milk attending: chief complaint: retroperitoneal bleed major surgical or invasive procedure: -abdominal angiogram with ir guided embolization of pseudoaneursym of l3 aorta branch () -abdominal angiogram with ir guided embolization of pseudoaneursym of l3 aorta branch () -picc line placement on left arm and then exchange by ir with power picc line -transesphageal echocardiogram history of present illness: ms. is a 81 yo female with hx of ra, with recent l4-l4 back laminectomy in , with chornic back pain, who had 5 recent kyphoplasties in flordia, after which deveoloped a rp bleed when being restarted on her anticoagulation for her st. mvr. she was transfered from today to be further treated. she had her vertebroplasty procedure in on . hemaglobin was before the procedure was 12 per son, then fell and she was given 2 units of blood on . she then had a upper and lower gi scope that found inflammation per son, but no bleeding in colon, duodeunum, and stomach. she was discharged on with stable blood counts. then felt severe abdominial pain the next day. she was taken to er and had a ct of the abdomen () that found a large pr bleed and a l3 fracture of the transverse process. she had been off anticaoguation during her kyphoplasty, and was restarted on 5mg for 2 days, then had an inr of 2.7 on . on the day of the rp bleed the inr was 5.1. she was given vitamin k iv and ffp. she had a repeat ct scan in 12 hours with no change. she was transfused 5 units over two days. then requested transfer to , where she has her regular care. (md # in fla is ). on the floor, minimal abdominal pain, no sob, no cp. would like to eat. understands risk of bleeding vs stroke. review of sytems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation. no recent change in bowel or bladder habits. no dysuria. past medical history: 1. rheumatoid arthritis. chronically on steriods 2. atrial fibrillation. 3. st. mechanical valve mitral valve replacement in . for hocm, 4. high cholesterol. 5. gastroesophageal reflux disease. 6. depression. 7. laminectomy of l4-l5 8. diastolic hf, ef 70% 9. osteoprerosis, multiple recent compression fractures social history: she lives alone, alternating here and in floridia. son is hcp. nonsmoker, no etoh, no drugs. able to do adls prior to admission. family history: non-contributory physical exam: on admission: vitals: t: 96 bp: 143/71 p: 80 r: 18 18 o2:98% 2lnc general: alert, oriented, no acute distress heent: sclera anicteric, dry membranes, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, no murmurs, loud click of heart valve throughout abdomen: soft, tender right side, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema changes on discharge: -hematoma on right thigh, medial and posterior, decreasing in size, tender -picc in place in left arm pertinent results: admission labs- 09:05pm blood wbc-11.6* rbc-3.92* hgb-11.5* hct-34.0* mcv-87 mch-29.2 mchc-33.8 rdw-14.5 plt ct-261 09:05pm blood pt-13.1 ptt-26.6 inr(pt)-1.1 09:05pm blood glucose-69* urean-10 creat-0.4 na-135 k-3.9 cl-98 hco3-26 angap-15 09:05pm blood calcium-8.5 phos-2.8 mg-1.8 urine studies- 10:20pm urine rbc-2 wbc-30* bacteri-mod yeast-none epi-0 10:20pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-2* ph-7.0 leuks-mod 10:20pm urine color-straw appear-hazy sp -1.007 10:20 pm urine source: catheter. **final report ** urine culture (final ): klebsiella pneumoniae. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s other labs- 02:08am blood wbc-14.6* rbc-3.44* hgb-10.2* hct-29.8* mcv-87 mch-29.8 mchc-34.4 rdw-15.6* plt ct-254 03:55pm blood hct-30.6* 07:05am blood wbc-13.8* rbc-3.06* hgb-9.1* hct-27.9* mcv-91 mch-29.8 mchc-32.8 rdw-15.5 plt ct-314 04:44pm blood wbc-22.0* rbc-3.94* hgb-12.0 hct-34.0* mcv-86 mch-30.3 mchc-35.2* rdw-15.1 plt ct-331 07:30am blood wbc-14.3* rbc-2.48* hgb-7.5* hct-22.4* mcv-91 mch-30.3 mchc-33.5 rdw-16.0* plt ct-316 04:09pm blood hct-31.4* 11:22pm blood hct-29.8* 06:15am blood wbc-7.3 rbc-3.42* hgb-10.3* hct-30.5* mcv-89 mch-30.2 mchc-33.8 rdw-16.0* plt ct-330 basic coagulation pt ptt inr(pt) source: line-picc 06:15am 14.1* 69.2* 1.2* renal & glucose glucose urean creat na k cl hco3 angap 06:15am 80 8 0.5 137 3.3 101 28 11 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos totbili dirbili 05:57am 19 26 477* 97 0.8 cpk isoenzymes ck-mb ctropnt 02:08am 3 <0.011 chemistry totprot calcium phos mg 06:15am 8.7 3.4 2.2 urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 11:37am sm neg neg neg neg neg neg 6.0 neg microscopic urine examination rbc wbc bacteri yeast epi 11:37am 6* 1 few none 0 4:44 pm blood culture source: line-picc #1. **final report ** blood culture, routine (final ): streptococcus anginosus (milleri) group. isolated from one bottle of one set only sensitivities requested by # . final sensitivities. sensitivity testing performed by sensititre. clindamycin = sensitive ( <=0.12 mcg/ml ). sensitivities: mic expressed in mcg/ml _________________________________________________________ streptococcus anginosus (milleri) group | clindamycin----------- s erythromycin----------<=0.25 s penicillin g----------<=0.06 s vancomycin------------ <=1 s 4:14 pm catheter tip-iv source: right picc line. **final report ** wound culture (final ): no significant growth. reports- ultrasound right lower extremity impression: no evidence for dvt in the right lower extremity. ekg cardiology report ecg study date of 10:04:44 am sinus rhythm. there are non-diagnostic q waves in the lateral leads. non-specific st-t wave changes. compared to the previous tracing st-t wave changes are less marked. intervals axes rate pr qrs qt/qtc p qrs t 75 140 82 422/448 36 2 -10 ct abd and pelvis without contrast impression: 1. more extensive retroperitoneal hematoma. 2. similar evidence of a focal dissection in the lower abdominal aorta, but most likely chronic and unlikely to relate to the recent retroperitoneal hemorrhage. u/s doppler le impression: no evidence for dvt in the right lower extremity. aortagram impression: 1. abdominal aortogram demonstrating a 2.6 x 1.6 cm pseudoaneurysm originating from the l3 lumbar artery. in addition, note was made of a focal 8 mm x 7 mm dissection involving the infrarenal abdominal aorta without evidence of extravasation corresponding with the patient's preprocedure cts. the ct of the chest from , which was performed prior to the kyphoplasty and showed similar appearance of the focal aortic dissection as seen on the recent exam of . 2. uncomplicated embolization of pseudoaneurysm using coils, gelfoam, and thrombin as described above. 3. completion abdominal aortogram demonstrating no flow to the pseudoaneurysm. tee the left atrium is normal in size. there is asymmetric left ventricular hypertrophy. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). diastolic function could not be assessed. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. a bileaflet mitral valve prosthesis is present. the mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trivial mitral regurgitation is seen. the degree of mitral regurgitation seen is normal for this prosthesis. there is no pericardial effusion. impression: normally functioning mitral prosthesis. asymmetric septal hypertrophy. normal regional and global left ventricular systolic function. cta abd/pelvis/le . impression: 1. new extensive right thigh hematoma with possible tiny focus of active extravasation. this hematoma appears separate from the retroperitoneal hematoma and may relate to the patient's anticoagulation. 2. unchanged appearance of iliopsoas hematoma. no definite opacification or extravasation from the known lumbar pseudoaneurysm status post coiling. 3. progressive thrombosis within the false lumen of the focal infrarenal aortic dissection. aortogram impression: 1. selective right third lumbar angiogram demonstrating residual filling of the previously embolized pseudoaneurysm. 2. successful coil re-embolization along the length of the l3 lumbar artery with complete stasis seen on follow-up post embolization angiography. 3. right common femoral angiogram demonstrating no evidence for contrast extravasation. incidental note made of moderate stenosis involving approximately 1-cm segment of the distal sfa near its junction with the popliteal artery. a small focal dilation in a peripheral medial profunda branch is noted corresponding to the findings on the ct from but unlikely to be related to the patient's hematoma. transesophogeal echo no spontaneous echo contrast is seen in the body of the left atrium. overall left ventricular systolic function is normal (lvef>55%). there are complex (>4mm) atheroma in the aortic arch and descending aorta. there are three aortic valve leaflets with moderate thickening and calcification but no vegetations. there is no significant aortic regurgitation. a bileaflet mitral valve prosthesis is present. no mass or vegetation is seen on the mitral valve. mild mitral regurgitation is seen that is normal for this type of prosthesis. the tricuspid and pulmonic valves were not well seen. there is no pericardial effusion. impression: no evidence of endocarditis on the bileaflet mechanical mitral valve or the native aortic valve. ct without contrast abd/pelvis impression: 1. stable to slightly decreased size of right psoas, right pelvic sidewall, and right thigh hematoma. no new hematomas are seen. 2. multiple embolization coils seen along the right psoas muscle at the l3 level. 3. extensive atherosclerotic calcification of the abdominal aorta and iliac arteries. 4. status post mitral valve replacement with sternal cerclage wires. 5. stable calcified pulmonary nodule, which may be related to prior granulomatous disease. 6. stable-appearing multilevel vertebral body compression fractures status post kyphoplasty. 7. diverticulosis without diverticulitis. brief hospital course: ms. is a 81 year old female with history of rheumatoid arthritis, with recent l4-l4 back laminectomy in , with chronic back pain, who had 5 recent kyphoplasties in , after which developed a retroperitoneal bleed from a pseudoaneurysm of the l3 artery and was transferred to to be started on anticoagulation for her st. mvr. # retroperitoneal bleed: based on imaging, likely from a pseudoaneurysm of the l3 artery branch of the aorta, which bleed in the setting of a supratheraputic inr after procedure. at the osh she required a total of 7 units of blood, and was transferred off anticoagulation with a stable hct. she was restarted on the heparin drip and her hct slowly trended down from 34 to 29 over 2 days, and given 1 unit of blood. repeat ct scan showed increased size of bleed. ir was consulted and on performed embolization with multiple coils of aneurysm. during this she had hypertension and some st changes consistent with demand ischemia. she was monitored in the micu overnight and restarted on heparin 6 hours post op. on she was noted to have increasing pain in her thigh, and her hct fell to 22.4. repeat cta showed increased bleeding from the same area and now the hematoma expanded into her thigh. she was given 2 units of blood and returned for a second ir guided embolization with additional coils, gel foam, and thrombin placed again. she was kept off heparin for 2 and half days post procedure. her hct had a slight decrease to 26 from 28 (thought to be from dilution from picc line), given one additional unit of blood. then heparin was restarted on , since then hct has been stable. . will need daily hematocrit check, and if concern for bleeding heparin drip should be stopped and consider ct with contrast. can have contrast with power picc that is in place. . # mitral valve replacement with mechanical st. : she requires long term anticoagulation from high risk of stroke and valve thrombosis. however, also has risk for rp bleed to worsen. see above for bleeding course. now restarted on heparin on . goal ptt of 50-70 to prevent rebleeding, q6h ptt checks, follow sliding scale. once stable for 1 week, consider restarting at rehab. patient is very sensitive to (was on 1.5 as out pt) and will likely need slow bridging on low doses. . # rheumatoid arthritis: patient on long term prednisone, was given 2 bursts of steroids during her admission due to increased knee pain and concern for possibility of adrenal insufficiency. was on 20mg for 3 days, then back to 5 mg per day; then after ir procedure had 2 days of 20mg, then 10mg x 1 day, and then back to 5 mg. during these times she had a leukocytosis of 22, and it was unclear if it was from the steroids vs the uti. improved by discharge with decreased steroids and antibiotics. . # pain: has pain in back and right thigh from chronic issues and from bleed. however, is very sensitive to pain medications. very easily over sedated and becomes delirious with narcotics. initially she was treated with morphine, this was then stopped, and her mental status and pain improved. she is now on tramadol tid and standing tylenol. also lidocaine patches. . # osteoporosis: multiple fractures, s/p kyphoplasty on 5 vertebral fractures. she has not been on a bisphosphonate and will need to be started on one. she was started on calcium and vitamin d. recommend out pt bone scan. . # st depressions with hocm: she developed st depressions with hypertension in setting of ir procedure, also had similar depressions in precordial and lateral leads in fl with initial bleed. she had no chest pain. resolved with treatment of blood pressure with metoprolol iv and labetalol iv. was ruled out for mi. likely from increased stress in setting of hocm. if hypertensive in the future cardiology recommends to treat with bb or ccb, and avoid agents that decrease preload due to her hocm. . # bacteremia: on she had culture bottles positive with streptococcus anginosus in setting of elevated wbc (also on high dose steroids). she was afebrile and also had a klebsiella uti at that time. she had 3 sets of negative cultures on vancomycin and was transitioned to ceftriaxone. due to hx of mechanical valve, tee was done to rule out endocarditis, was negative study. per infectious disease recommendations, pt to complete course of ceftriaxone on for 2 week course. . # uti: klebsiella pneumonia, had foley from outside hospital. also had elevated wbc as noted above. was first treated with cipro, then once on ceftriaxone this was stopped. she completed a 10 day course and had foley removed. no bladder obstruction. . # diastolic heart failure: chronic, no heart failure sx during admission. . # hypertension: only had increased bp during ir procedure to 160s. otherwise controlled on metoprolol 25 . . # hyperlipidemia: was continued on statin . # gastritis: seen on recent egd at osh, may be secondary to chronic steroids. she was placed on ppi and continued at discharge. no epigastric pain. . # nutrition: very poor po intake during admission. seen by nutrition. once bleed was treated and narcotics stopped. pt was more responsive and has started to have more po intake. passed a swallowing study. needs encouragement to eat and assistance in feeding. supplement drinks between meals. . # communication: patient, son is hcp day night cell . # she is being discharged to rehab for further care and physcial therapy. medications on admission: acetaminophen docusate sodium ferrous sulfate fluoxetine lansoprazole oral disintegrating tab ondansetron prednisone simvastatin vitamin d zolpidem tartrate discharge medications: 1. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 2. simvastatin 40 mg tablet sig: one (1) tablet po hs (at bedtime). 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 5. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours): max 4g per day. 6. tramadol 50 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for pain: hold for sedation. 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for pain: on for 12 hours, off for 12 hours . 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day): hold for loose stool. 9. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day): apply to buttocks rash. 10. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for painful tongue. 11. 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. 12. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 13. heparin (porcine) in ns 10 unit/ml kit sig: one (1) intravenous drip: drip as per d/c instructions, goal ptt 50-70. 14. ceftriaxone 1 gram recon soln sig: one (1) intravenous once a day for 6 days: last day . 15. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 16. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp<100, hr<60. 18. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 19. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 21. bisacodyl 5 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary- retroperitoneal bleed from 3rd lumbar pesudoaneursym secondary- demmand ischemia in setting of hypertrophic obstructive cardiomyopathy bacteremia with strep anginosus urinary tract infection mitral valve replacement requiring anticoagulation hypertension discharge condition: hemdynamically stable, afebrile, on heparin drip discharge instructions: you were admitted to due to needing to restart your anticoagulation in a setting of a bleed after your kyphoplasty. you had two procedures to stope the bleeding. you have now been restarted on your heparin. you will start your next week. you also were treated with anitbiotics for a bladder infection and a possible blood infection. your last day of antibiotics will be . it is improtant that you eat in order to heal. you will be going to a rehab to gain your strength and improve your eating. please call to make an appointment with you primary care docotor once you leave the rehab center. if you have chest pain, shortness of breath, new abdominal pain, new weakness, problems with , fainting, or other concerning symtpoms please seek medical attention or go to the er. followup instructions: please call to make an appointment with you primary care docotor once you leave the rehab center. pcp: , s. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart aortography other surgical occlusion of vessels, abdominal arteries other surgical occlusion of vessels, abdominal arteries diagnoses: esophageal reflux pure hypercholesterolemia urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site adrenal cortical steroids causing adverse effects in therapeutic use acute posthemorrhagic anemia depressive disorder, not elsewhere classified heart valve replaced by other means bacteremia osteoporosis, unspecified long-term (current) use of anticoagulants retention of urine, unspecified pressure ulcer, lower back other constipation rheumatoid arthritis other diseases of lung, not elsewhere classified nontraumatic hematoma of soft tissue streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus spinal stenosis, unspecified region unspecified gastritis and gastroduodenitis, without mention of hemorrhage diverticulosis of colon (without mention of hemorrhage) chronic diastolic heart failure hemoperitoneum (nontraumatic) hemorrhage, unspecified pressure ulcer, stage i dissection of aorta, abdominal pathologic fracture of vertebrae other acute and subacute forms of ischemic heart disease, other dysphagia, unspecified aneurysm of other specified artery 

Answer: The patient is high likely exposed to