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 attending: chief complaint: back pain major surgical or invasive procedure: washout of l prosthetic hip washout of l knee x 2. debridement of epidural abscesses. transesophageal echocardiogram placement of r ij central line placement of l antecubital picc line. history of present illness: 55 yo f s/p l hip replacement 3 years ago now transfered from with mssa bacteremia with evidence of infection of l hip, possible l knee, lumbar spine, urine, blood, and emboli to brain. . pt states she was in her usoh until when she drove her son to college. states she began having left lower back pain radiating to l leg. per her husband she had not previously been on narcotics, but was given several prescriptions after a few ed visits, neurology visit, and pcp visit in the past few weeks for this pain. she states that leading up to she had noticed some chills and nausea. she also had a severe headache and some neck stiffness. her family states she was not eating or drinking much at all. she denies bowel or bladder incontinence but states sometimes she would have to cough to get her urine stream to start. states over the 3 weeks she felt her legs getting weaker l>r. on pt drove to for a bone scan that had been ordered by her neurologist. her wbc count had been elevated and there was concern for myeloma vs. infection. however, she only finished the 1st half of the scan and then drove home. she was found on the front step of her house by her neighbor struggling to get in the front door with altered mental status. it was not known how long she had been sitting there. she complained of bilateral leg weakness with pain in her left lower back that radiated down her l leg. ems reports her bp was low at 90/68 and initially improved with ns but then decreased again. at she was found to have rhabdomyolysis with a ck of 3738 and a wbc of 16. na was 119 and cl was 87. cr was elevated at 3.8 (baseline 1.1) and uti was diagnosed. cxr showed bilateral infiltrates. ddimer was positive but v/q scan was low prob for pe. she was started on levofloxacin and vancomycin as well as hydrocortisone for the hypotension. head ct showed embolic disease. she began spiking fevers and blood cultures and urine culture grew out mssa. she complained of back and l hip pain and a fluid collection was seen in the hip and aspiration showed 66,000 wbc's and grew out mssa as well. lumbar mri possible epidural abscess l2-4. troponin was initially 0.04 but then became elevated and peaked at 17.19 on . this was felt to be an nstemi in the setting of demand from septic shock. she was started on aspirin and beta-blocker. renal failure resolved with fluids. . on admission to micu pt c/o severe lower back pain radiating down l leg. states l knee is very painful and she cannot move the l leg much pain. pt states her ms was initially poor but has since cleared and she is now at baseline with regards to mental functioning. past medical history: -htn -sciatica (was diagnosed 6-7 years ago, but pt states she has not had any back pain since then until .) -s/p left hip replacement 3 years ago. -h/o cervical cancer s/p xrt 4 years ago. -h/o barrett's esophagus in the distant past. social history: lives in with husband and daughter. denies smoking, etoh, or drugs. family history: father died at 61 with heart disease. mother is in a nursing home physical exam: admission exam: pe: 100.2, 131/71, 105, 20, 96% on ra gen: slightly somnolent but arouses to voice. heent: perrla, eomi. mouth extremely dry with cracked lips and dried blood on tongue. neck: supple, no lad. excoriation under chin (pt states was from c-collar that was initially placed by ems) cv: tachy, regular, no m/r/g abd: obese, s/nt/nd, +bs ext: well healed scar on lateral aspect of l hip. legs are puffy bilaterally but no edema. neuro: a&ox3. cn 2-12 in tact. strength 5/5 in ue's bilaterally. 4+/5 in r leg, 2+/5 in hip flexors, 2+/5 in hamstrings and quads (exam limited by pain). pt has extreme pain on passive bending of l knee. ankle dorsi- and plantar-flexion bilaterally. sensation in tact to lt throughout except on ball of l foot which pt states is decreased. toes upgoing bilaterally. rectal: good tone. guaiac positive brown stool. pertinent results: studies from caritas : . cxr : diffuse infiltrates suspected for pneumonia. . pelvis ap view : multiple surgical clips noted. possible ln dissection. prosthetic l hip and acetabulum. . 2 views of l shoulder : normal. . v/q scan: low prob for pe. . renal ultrasound : normal. . ct chest without contrast : patchy streaky densities in the lung bases posteriorly on both sides probably small zones of atelectasis or scarring. some minimal thickening of the pleura posteriorly especially at the r lung base. no pleural effusions or confluent consolidations. . tte : lvef 60%, mild hypokinesis of rv infervior wall. 1+ tr, borderline pulm htn. no vegetations seen. . mri head : wet read: multiple old infarcts. r temp and occipital cortical infarcts - acute. no enhancement. . mri lumbar spine: djd l2-3, , . marked stenosis of l3-4. large cyst in r hemipelvis - ?r ovarian cyst. s/p hysterectomy. . cxr : streaky bilateral basilar atelectasis. . mri c/t/l spine : wet read: c-spine - unremarkable. t-spine: enhancing lesion (intraderual, extramedullary) upper to lower thoracic spine with anterior displacement of the spinal cord, suspicious for tumor vs. infection vs. vascular malformation. l-spine: extension of the enhancing lesion in the dura to the upper lumbar spine. multilevel djd most prominent at l3-4 with central canal stenosis. . ct abdomen/pelvis without contrast and ct guided aspiration of l hip joint : mild to moderate ileus - no acute intra-abdominal abnormalities. ct guided biopsy performed. . mri tls spine : t spine limited by movement, 1. spondylodiscitis at the l2/l3 through the l5/s1 levels with large epidural abscesses extending from the l2 to the s1 levels causing mild canal stenosis at the l1 and l2 levels and moderate-to-severe canal stenosis at the l4 and l5 levels. this appears not significantly changed since . 2. extensive right psoas muscle and left erector spinae muscle abscesses which are worsened since . 3. leptomeningeal enhancement of the conus and well as the pachymeningeal enhancement of the thecal sac, as before, concerning for subarachnoid vs subdural abscesses. labs from before transfer: wbc 12.5 (93.7% polys, 4.7% lymphs), hct 28.5, plt 316, na 130, k 3.7, cl 99, co2 27, bun 19, cr 1.0, ca 7.3, t.bili 2.1, dir bili 0.6, alk phos 87, alt 36, ast 46, alb 1.1, t.prot 5.9, trop 4.41 (trend 0.04 on admission -> 11.54 on -> 17.19 on -> 6.35 on -> 4.41 on ). inr 1.2. bnp 379. ldl 98. . culture data from osh: . aspiration : gm stain negative, fluid culture: moderate growth of staph aureus, resistant to penicillin but sensitive to oxacillin and all others. . blood cultures: : staph aureus (grew in <24 hours) in bottles. r to penicillin but to all others inc oxacillin. : mssa . u/a on admission : large blood, 100 protein, large le, innumberable rbc's and wbc. epithelial cells, many bacteria. . urine culture: : staph aureus >100,000 cfu/ml. r to penicillin but to all others inc oxacillin. . : knee and hip fluid: mssa. . ecg : sinus tach at 115, rbbb. downsloping st depressions in i, avl. q in iii, avf. t wave inversions with downsloping st segments in v1-v5. . studies at : . tee : mobile, linear echodensity as described above on the aortic valve as described above. though atypical in appearance and location, this abnormality is consistent with a vegetation. . tte : . mild symmetric lvh. lvef 60-70%. rv size and free wall motion nml. no ar. trivial mr. 2+ tr. trivial/physiologic pericardial effusion. . bilateral leni's and : no evidence of dvts. . mri c-spine : no evidence of epidural abscess or abnormal pathologic enhancement within the cervical spine. . mri t and l-spine : spondylodiscitis at the l2/l3 through the l5/s1 levels with large epidural abscesses extending from the l2 to the s1 levels causing mild canal stenosis at the l1 and l2 levels and moderate-to-severe canal stenosis at the l4 and l5 levels. this appears not significantly changed since . 2. extensive right psoas muscle and left erector spinae muscle abscesses which are worsened since . leptomeningeal enhancement of the conus and well as the pachymeningeal enhancement of the thecal sac, as before, concerning for subarachnoid vs subdural abscesses. . mri t and l-spine : status post laminectomies from l2 to s1 level with decrease in epidural abscess. some residual epidural fluid collection is seen at l2 and l4 level as described above. area of low signal at the laminectomy site within the surgical cavity, which compresses the thecal sac from posterior aspect could be due to blood within the surgical cavity or postoperative fluid collection. a drain is identified within this cavity. leptomeningeal and pachymeningeal enhancement is seen in the lumbar thecal sac. right psoas abscess is again identified and is unchanged. . 6:34 am urine source: catheter. urine culture (preliminary): citrobacter freundii complex. >100,000 organisms/ml.. trimethoprim/sulfa sensitivity testing confirmed by . this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. non-fermenter, not pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter freundii complex | non-fermenter, not pseudomonas aerugin | | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 32 s piperacillin---------- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: a/p: 55 yo f with h/o l hip replacement and djd of lumbar spine now with mssa bacteremia with infection of urine, l hip, l knee, intradural/epidural abscesses, aortic valve, psoas and erector spinus muscle abscess, and emboli to brain: . # mssa bacteremia: unclear etiology - could have started with skin infection that seeded hip and then to other areas afterwards. use of steroids in setting of infection likely allowed for further spread. pt will need to be treated with nafcillin 2g iv q4 indefinitely given extensive spread of infection. she will follow up with dr. in id and needs to have weekly labs sent to him (see page one). kidney function especially needs to be watched given cr is rising, however, id has stated that they would only consider changing nafcillin if kidneys severely worsened given that it is such a superior would prefer not to change unless absolutely necessary. at all blood cultures were ngtd since . no longer checking surveillance cultures since would not change management. picc placed for long-term nafcillin. . # l hip infection and l knee infection: mssa grew out of hip and knee. ortho consulted - washed out knee and hip on . returned to or for washout of knee only given purulent drainage and persistent pain on . last procedure on l knee was so is now pod #12 on . as for the hip, last procedure was so she is now pod #16 on . both l hip and knee staples need to be removed on . of note the hip has still be having some serosanguinous fluid drainage which needs to be watched and if it is accumulating rapidly dr. office needs to be notified at . dry sterile dressings should be placed over this wound, while the knee can be kept open to air. follow up with dr. is arranged for . . # epidural/intradural abscess: neurosurg and ortho spine had a combined conference to discuss and felt that intradural abscess spanned t3-l3 and that debridement would be too morbid and pt would not tolerate. however epidural abscess in l3-s1 was able to be drained so ortho spine (dr. ) took to the or on and drained abscess. c-spine negative for abscess. given weakness, per neuro recs who discussed with id started steroids dexamethasone 10 mg iv x1 and the 4 mg q6h. given pt responded with likely steroid induced psychosis on second day, cut dose in half and cut in half again - has been doing well since. currently on steroid taper - on prednisone 20mg to be tapered quickly per page one. dry sterile dressings should be placed on the wounds and the staples should be removed on . if the wound is worsening or problems arise, please contact dr. at . pt has followup with dr. on . . # psoas/erector spinae abscesses: first detected on mri done (was not present on films from osh). not drainable by ir (felt that there were too many little abscesses and putting a drain in one or two would not help). consulted surgery but they also felt no intervention would be helpful. ortho spine and id agreed need to reimage with possible ct in 2 weeks to determine if abscesses are enlarging and would be amenable to drainage. pt had a very difficult time tolerating mri's so it was hoped that a ct with contrast could be used, however, now that her cr is worsening this may not be an option and an mri might need to be used. this scan needs to be completed before the patient sees dr. in id on . . # anasarca: pt was given over 30 l of fluid and blood and now has anasarca with impressive edema in bilateral legs and arms. it is likely that the edema is making movement more difficult. on she was given a dose of 20mg iv lasix with albumin, and had some urine output, but cr subsequently increased from 1.3 to 1.5. the plan is now to place teds/ace bandages on her lower extremities to try to squeeze some of the fluid into her vasculature to help diuresis. once her cr improves or becomes more stable trials of lasix may be done again. . # pain management: initially was placed on dilaudid pca with boluses but after surgery in knee, hip, and epidural abscesses pain seemed to improve. pain has improved and she has been transitioned to a fentanyl patch with oxycodone for breakthrough pain (needs be used before turning and moving as this is when pain is worst). this should be titrated as needed. . #emboli in brain: osh films were shown to radiology at who agreed was concerning for embolic strokes. has evidence of vegetation on aortic valve. concern for abscess in brain by neuro but neuro exam has improved and not worsened so feel that repeat mri would not change management currently. dr. with neurology needs to see patient in followup - please call to arrange this (dr. office was unavaiable on pt's d/c to rehab). . # diarrhea: was concerning for c.diff and pt was empirically started on flagyl for a few days but stool samples returned negative x 3 so flagyl was stopped. . # hyponatremia: na was initially 116 at osh, has improved to 135. likely was from volume depletion since pt and family state she has not been eating or drinking for last few weeks. she was bolused with ns aggressively and hyponatremia corrected. . # arf/urinary tract infection: bump in cr from 1.1 to 1.3 to 1.5. urine eos were rare positive on repeat again rare positive eos. ua showed 50wbc and grew out , foley changed and resent - again >50wbc. id initially suspected not uti but rather ain causing white cells in urine given culture grew only . concern for prerenal versus ain versus to ace inhibitor - d/c'd lisinopril. given clear superioroity of nafcillin to vanco will try to keep nafcillin as long as possible. cr was improving s/p d/c of lisinopril and improvement of fluid status (s/p many boluses of fluid and blood after or) but then in the last 2 days has worsened (1.3 to 1.5). this was in the setting of trying to diurese with lasix. this needs to be followed very carefully with possible need for renal consult in the near future. current plan is to hold off on lasix and see if cr stabilizes. since ua was positive and urine culture grew out citrobacter, id recommended treating with ciprofloxacin for 7 days (day 1 ). another isolate was also seen on this urine culture and identification is still pending and needs to be followed up on. . # anemia: pt was persistently guiaic positive on exam. possible stress ulcer in setting of severe illness. hemolysis labs negative. was given 2 units prbc's on and bumped from 24 to 33, but then trended back down to 24 on and was given 1 more unit prbc's. given 2uprbc on . given one further unit before discharge on . she was started on protonix 40mg iv bid, switched to po lansoprazole . consulted gi to consider scope, but they wanted to hold off for now given hct has been relatively stable and still in peri-mi setting. hct should be checked at least every other day for now, especially while guaiacs are positive. . # h/o nstemi at osh: was attributed to demand in setting of hypotension and tachycardia. trop peaked at 17. ecg at shows downsloping st segments with t wave inversions. tte showeed no focal wma. tee showed vegetation only. cardiology consulted and medical managment for now given overall illness. she was started asa 325mg po daily on . bb and high dose statin started per cardiology. initially started acei but then d/c'd given arf. daily ecg's were relatively unchanged. . # dry mouth/dried blood on tongue and lips: likely from dehydration with poor po intake. inr slightly elevated at 1.3 - likely from nutritional deficiency. placed dobhoff with tf for nutritional improvement. mouth swabs to keep mouth moist. needs aggressive mouth care. viscous lidocaine was initially used to help with pain and sore throat but this has improved and lidocaine has not been needed. gave 5mg po vitamin k x 3 days on arrival - inr corrected. . # anxiety/depression: all of these events were very stressing to the patient and she became very anxious. she was started on paroxetine to help with this and also was given ativan prn. the ativan was felt to be helpful and on the day of discharge this was changed to clonazepam tid. . # access: very poor peripheral access. iv was not able to place peripheral. central line placed to allow for blood draws and antibiotics - was d/c'd . picc placed . . # fen: given low albumin and very poor intake placed dobhoff tube and started tubefeeds per nutrition recs. . # ppx: checked q3d lenis x 2 which were negative, heparin sq and pnaboots. ppi, bowel regimen. . # comm: with patient and family (husband and 2 daughters). pt states her eldest daughter is hcp. below. . # sw consult for pt/family coping given very grim prognosis and inability to discuss this with patient given she becomes very upset and emotional at beginning of any conversation which involves likely poor outcome. her coping improved throughout the hospitalization, and it was explained that her condition carries a very large mortality. . # full code. medications on admission: *per patient and family before the back pain started 3 weeks ago she was only on: -lisinopril unknown dose -prilosec daily *in the last few weeks she had been prescribed the following by various physicians: -gabapentin 300mg po tid -diazepam 5mg po q8 -prednisone on a tapering dose at 50mg, finishing the last dose on -diclofenac 75mg po bid -hydrocodone 1-2 tabs po q4 -oxycodone 1 tab po q6 discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. simvastatin 40 mg tablet : two (2) tablet po daily (daily). 3. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed. 4. heparin (porcine) 5,000 unit/ml solution : 5,000 units injection tid (3 times a day). 5. aspirin 325 mg tablet : one (1) tablet po daily (daily). 6. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical qid (4 times a day) as needed. 7. paroxetine hcl 20 mg tablet : one (1) tablet po daily (daily). 8. quetiapine 25 mg tablet : one (1) tablet po bid (2 times a day) as needed. 9. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 10. sucralfate 1 g tablet : one (1) tablet po qid (4 times a day). 11. metoprolol tartrate 50 mg tablet : two (2) tablet po tid (3 times a day). 12. fentanyl 25 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 13. oxycodone 5 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 14. prednisone 20 mg tablet : one (1) tablet po daily (daily) for 2 days: last dose 4/6. . 15. prednisone 10 mg tablet : one (1) tablet po daily (daily) for 2 days: . . 16. prednisone 5 mg tablet : one (1) tablet po daily (daily) for 2 days: . . 17. clonazepam 0.5 mg tablet : one (1) tablet po tid (3 times a day): hold for somnolence or rr<12. 18. nafcillin 2 gm iv q4h 19. heparin lock flush (porcine) 100 unit/ml syringe : two (2) ml intravenous daily prn as needed: 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. . 20. prochlorperazine edisylate 5 mg/ml solution : 5-10 mg injection q6h (every 6 hours) as needed. 21. cipro oral 22. ciprofloxacin 500 mg tablet : one (1) tablet po q12h (every 12 hours) for 7 days. discharge disposition: extended care facility: discharge diagnosis: mssa bacteremia with bacterial infections of: l knee s/p washout l prosthetic hip s/p washout epidural/intradural abscess psoas and erector spinae abscess aortic valve vegetation emboli to brain urinary tract infection. infections above complicated by: anemia - likely gi bleed nstemi arf hyponatremia (resolved) diarrhea anasarca discharge condition: stable. discharge instructions: renal function has been changing and will require daily monitoring. please see d/c summary for more details. followup instructions: please keep the following follow up appointments - they are very important. all of these appointments are at . 1) ortho spine - dr. - thursday at 8:35 a.m. on the in the building. 2) ortho knee/hip - dr. - thursday at 10:00 a.m. on the in the building (same suite as the appointment with dr. ). 3) infectious disease - at 11:00 a.m. with , md in the . weekly labs cbc with diff, bun and cr, lft's, need to be faxed to dr. at . before this visit, the patient needs to have repeat imaging of her psoas abscess - a ct with contrast vs. mri - need to consider renal function before deciding which test should be done. be aware that pt needs to be heavily sedated before mri's. 4) neurology - dr. - please call and ask for to schedule the appointment (will be in approx 6 weeks but please call soon as appointments fill up quickly). procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances other exploration and decompression of spinal canal transfusion of packed cells synovectomy, knee other arthrotomy, knee other arthrotomy, hip diagnoses: sciatica subendocardial infarction, initial episode of care urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension adrenal cortical steroids causing adverse effects in therapeutic use acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) severe sepsis methicillin susceptible staphylococcus aureus septicemia personal history of malignant neoplasm of large intestine acute and subacute bacterial endocarditis surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation cerebral embolism with cerebral infarction dehydration intraspinal abscess drug-induced delirium barrett's esophagus personal history of irradiation, presenting hazards to health intracranial abscess infection and inflammatory reaction due to other internal orthopedic device, implant, and graft psoas muscle abscess unspecified inflammatory spondylopathy pyogenic arthritis, lower leg disturbance of salivary secretion 

Answer: The patient is high likely exposed to