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: fevers major surgical or invasive procedure: ? history of present illness: the patient is a 79 year old man with history of pvd, dm2, and recent osteomyelitis () referred from for management of endocarditis and discitis. he presented on with fever and pain in the inner aspect of his groin. he also had pain in his back. he had some pain in his mouth as well that was concerning of necrotic mandibular abscess. . hosp course: admitted on empiric vanc/levo/flagyl in ed. blood cultures grew . had concern for mild renal insufficiency on admission and had potential history of ain induced by nafcillin so treated with vancomycin. he remained afebrile until the night of at which time he spike to 101. ct abd on showed l1-l2 infectious discitis, marked rectal distension from stool. ct head had no mandibular mass. on he had mri of the left ankle that showed subchondral marrow edema suggestive of osteomyelitis. normal lvef, marked concentric lvh and 1.1 cm mobile density on posterior leaflet of mitral valve with trace mitral insufficiency. also, his blood sugars were persistently low requiring holding of his lantus and a d10w infusion. . prior to transfer he spike another fever to 102. blood cultures were drawn. kefzol added to regimen on . he was transferred for further evaluation. . in the micu he remained hd stable. his antibiotics were switched to nafcillin and gentamycin. a neurosurgery consult, an id consult, and a podiatry consult were obtained. . past medical history: pmh: dm type ii - insulin dependent glaucoma gerd bleeding peptic ulcer hx of mrsa bacteremia osteomyelitis of left foot due to poorly healing wound ( and ) hypothyroidism legally blind . surgical history: prior right tkr (complicated by infection) s/p left tka s/p left carotid endarterectomy right total shoulder replacement pvd: : right ak popliteal to dp bypass graft/ foot debridement social history: he is a retired police officer, currently lives with his wife, quit smoking 20 years ago, smoked from age 14-58 about 2ppd, no etoh x1year. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: vs: 96 70-84 112/43 97% ra wt: 97.4 kg (bedscale) gen: nad heent: at, nc, sun glasses. left eye patch, op clear, dry mm, edentulous except for 1 black tender tooth fragment on l mandible. neck supple, no lad, carotid bruit on right cv: rrr, nl s1, s2, 3/6 systolic murmur at apex radiates to axilla pulm: ctab, no w/r/r with good air movement throughout abd: soft, minimal tenderness to llq, nd, + bs, no hsm ext: 1+ edema to ankles. right knee in imobilizerwarm, dry, +2 distal pulses pt, no femoral bruits. closed heal ulcer on left. neuro: alert & oriented x2. cn v intact. cn vii-xii intact. strength: nl tone and bulk. hand grip bicep tricep hip flex bilat plantar flex bilat great toe dorsiflex 5/5 l, r : lightouch intact to face/hands/feet. no sensory level alongs legs/torso to pinprick dtr: diminished throughout psych: appropriate affect skin: stage i sacral pressure ulcer. pertinent results: 04:12am blood wbc-8.2 rbc-3.37* hgb-9.7* hct-29.9* mcv-89 mch-28.8 mchc-32.4 rdw-14.8 plt ct-192 05:25am blood wbc-5.1 rbc-3.18* hgb-9.7* hct-28.5* mcv-90 mch-30.5 mchc-34.1 rdw-15.2 plt ct-177 04:12am blood neuts-77.4* lymphs-17.4* monos-3.1 eos-1.9 baso-0.1 04:12am blood pt-20.4* ptt-37.9* inr(pt)-1.9* 05:25am blood pt-30.0* ptt-37.5* inr(pt)-3.1* 06:30pm blood fdp-10-40 06:30pm blood fibrino-209 05:25am blood esr-78* 05:30am blood esr-90* 04:12am blood glucose-97 urean-15 creat-0.8 na-134 k-4.6 cl-107 hco3-20* angap-12 05:25am blood glucose-101 urean-18 creat-1.4* na-136 k-3.5 cl-107 hco3-21* angap-12 04:12am blood alt-11 ast-53* alkphos-85 totbili-1.5 05:25am blood calcium-7.5* phos-3.3 mg-2.2 iron-76 05:25am blood caltibc-122* ferritn-1308* trf-94* 05:25am blood crp-172.5* 05:30am blood crp-138.3* 05:36am blood lactate-1.1 03:18am urine color-yellow appear-clear sp -1.010 12:55pm urine color-yellow appear-clear sp -1.014 12:55pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-2* ph-5.5 leuks-neg 12:55pm urine rbc-3* wbc-10* bacteri-few yeast-none epi-0 transe-<1 12:55pm urine mucous-rare 12:55pm urine eos-negative 05:33pm urine hours-random creat-66 na-61 06:04am blood wbc-7.8 rbc-2.83* hgb-9.0* hct-25.2* mcv-89 mch-31.7 mchc-35.6* rdw-18.0* plt ct-181 05:44am blood neuts-64.8 lymphs-25.3 monos-4.6 eos-4.9* baso-0.4 06:04am blood plt ct-181 06:13am blood pt-17.5* ptt-37.3* inr(pt)-1.6* 05:20am blood fibrino-260 06:30pm blood fdp-10-40 05:25am blood fibrino-264# 06:30pm blood fibrino-209 05:30am blood esr-90* 04:25am blood ret aut-3.9* 06:04am blood glucose-122* urean-31* creat-2.0* na-138 k-3.8 cl-107 hco3-23 angap-12 04:30am blood totbili-2.3* 04:25am blood ld(ldh)-327* totbili-1.6* 05:44am blood totbili-1.4 06:36am blood totbili-1.2 04:52am blood totbili-1.2 06:00am blood totbili-0.9 06:13am blood totbili-0.9 06:04am blood calcium-7.9* phos-3.6 mg-1.9 04:30am blood totprot-5.9* calcium-7.5* phos-4.1 mg-2.0 05:25am blood caltibc-122* ferritn-1308* trf-94* 04:18am blood hbsag-negative hbsab-negative hbcab-negative 04:18am blood ama-negative 04:18am blood -negative 04:18am blood afp-1.6 05:30am blood crp-138.3* 04:30am blood pep-polyclonal igg-2366* iga-593* igm-68 04:25am blood c3-115 c4-21 06:48pm blood vanco-28.2* 01:45am blood lactate-0.9 04:18am blood hereditary hemochromatosis mutation analysis-pnd sm antibody and alpha-1-antitrypsin negative . cxr: the heart size is mildly enlarged but stable. mediastinal contours are unremarkable. the bibasal retrocardiac opacities are demonstrated consistent most likely with atelectasis. the rest of the lungs are unremarkable but note is made that the right lateral chest wall and the right lateral lung were not included in the field of view. there is no evidence of pneumonia or large amount of pleural effusion . mri pelvis: : no fracture or dislocation is identified. degenerative changes are seen involving the right hip with a subchondral cyst noted within the right acetabular roof. a joint effusion is not present. no edema is seen within the greater trochanter to suggest greater trochanteric bursitis. diffuse high signal on t2-weighted imaging is seen involving the imaged muscles, particularly both iliopsoas muscles, and the subcutaneous tissues, compatible with diffuse edema. additionally, focal area of abnormal high signal on t2- weighted images is seen involving the origin of the right hamstring muscles, compatible with a partial tear. there is diffuse fatty atrophy of the imaged muscles, particularly the gluteus muscles on the right. no focal fluid collections to suggest an abscess are identified. bone marrow signal is within normal limits. the patient's known osteomyelitis involving the superior lumbar spine is not imaged on the current examination. the sacroiliac joints demonstrate small marginal osteophytes but otherwise are within normal limits. high signal on pre-contrast t1-weighted images is demonstrated within the bladder, compatible with residual gadolinium from a previous mr examination. a foley catheter is seen within the bladder, which contains a small focus of air within the lumen. the bladder otherwise appears unremarkable. there is small amount of ascites demonstrated within the pelvis. diffuse wall thickening is seen involving the rectum and sigmoid colon. small fat- containing bilateral inguinal hernias are present, with the left inguinal hernia containing a small amount of fluid. impression: 1. residual contrast within the bladder identified on the pre-contrast images, likely from the lumbar spine mr examination performed on at an outside institution. the presence of contrast on this examination from suggests impaired excretion of gadolinium from the body. correlation with the patient's renal function is recommended. additionally, dialysis should be considered. findings discussed with on the afternoon of , . 2. partial tear involving the origin of the right hamstring muscles. 3. diffuse anasarca and small amount of ascites in the pelvis. wall thickening involving the sigmoid colon and rectum likely secondary to third spacing of fluid. 4. diffuse muscular atrophy. 5. no evidence of osteomyelitis or abscess within the imaged portion of the pelvis . mri right knee: 1. presence of intra-articular gadolinium on the pre-contrast sequences indicates retention and excretion of contrast which was administered for a previous mr examination on . please note that the patient has had three mris with intravenous gadolinium in the span of three days (at 2 different institutions), and the presence of intra- articular gadolinium on the current study (and in the urinary bladder on the pre-contrast images from the previous study) suggests renal impairment and decreased clearance of gadolinium. correlation with patient's creatinine levels and consideration of dialysis is recommended. no further mr examinations with gadolinium is recommended in the near future until the patient's renal function has been evaluated. findings discussed with dr. on . 2. status post removal of total knee replacement with methyl methacrylate in the removed hardware beds. periprosthetic fluid is seen surrounding the methyl methacrylate components, which is in continuity with the joint space, a nonspecific finding. mri cannot distinguish between edema related to post-surgical changes and edema related to infection. no discrete abcess is identified. 3. diffuse edema within the subcutaneous tissues of the knee. 4. diffuse regional muscular atrophy. . tee: no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is mildly depressed. the descending thoracic aorta is mildly dilated with simple atheroma. the aortic valve leaflets are moderately thickened and calcified. no mass/vegetation is visualized on the aortic valve. mild aortic stenosis is present. the mitral valve leaflets are mildly thickened. there is a large mass measuring (1.7cm x 2.6 cm) present on the posterior leaflet of the mitral valve this mass is heterogeneous in appearance and can be seen to prolapse back and forth through the mitral annulus. mild (1+) mitral regurgitation is seen. the tricuspid valve has a normal structure with no evidence of any mass or vegetation present. no mass or vegetation is visualized on the pulmonary valve. conclusions: large mass on the posterior leaflet of the mitral valve measuring (2.6 x 1.7cm) which is likely a vegetation with mild (+1) mitral regurgitation. no other vegetations or abscesses seen. mild aortic stenosis. ecg: sinus rhythm. left anterior fascicular block. low limb lead voltage. delayed precordial r wave transition. cannot exclude prior anterior myocardial infarction. compared to the previous tracing of no diagnostic interim change. . ct abd w&w/o c 4:43 pm ct abdomen with and without intravenous contrast: in the imaged lung bases, there are moderate-sized bilateral pleural effusions with associated compressive atelectasis. no pulmonary nodules or pneumothorax is seen. the heart and great vessels appear normal excepting for atherosclerotic calcification in the a vascular including coronary arteries. the liver has a nodular surface and there is a 2.4 cm lesion in segment ii that demonstrates arterial enhancement with rapid washout, suspicious for hepatocellular carcinoma. the portal vein and its tributaries are patent with no evidence of thrombosis. the celiac axis and its tributaries have a normal anatomy and are patent, notwithstanding extensive atherosclerotic changes. there is a persistent exophytic right renal cyst posteriorly. the spleen is of normal size, and there is a hypodensity, likely a cyst. the pancreas is atrophic; the left kidney and adrenals are normal. the gallbladder contains gallstones. there is moderate amount of ascites and considerable anasarca. abdominal loops of bowel are unremarkable, and there is no abdominal pathologic lymphadenopathy or free air. ct of pelvis with and without contrast: in the pelvis, the sigmoid is dilated and the wall thickened with perisigmoid fat opacification suggestive of proctitis. there is a left fat and ascites containing inguinal hernia. the bladder and distal ureters appear normal and the foley catheter is seen in place. there are phleboliths. there is no pelvic free air and no gross pelvic lymphadenopathy. musculoskeletal: there are degenerative changes at numerous levels and at l1- l2, there is extensive destructive erosion of the disc and adjacent vertebral bodies. impression: 1. arterially enhancing lesion in segment ii of the liver with rapid washout likely hepatocellular carcinoma. 2. diskitis/osteomyelitis at l1-l2. 3. likely proctitis. 4. anasarca including ascites and new moderate bilateral pleural effusions (with associated compressive atelectasis). . abdomen u.s. (complete study) 9:51 am abdominal ultrasound: the liver is coarse in echotexture and nodular, consistent with cirrhosis. there is a new small hypoechoic nodule seen within the left lobe superiorly (segment ii), measuring 2 x 1.8 x 1.6 cm (images 12 and 13). the nodule is hypoechoic, with no vascularity, however suspicious for malignancy in this patient with underlying cirrhosis. no additional focal hepatic lesions are seen. there is no bile duct dilation. the common duct measures 3 mm. the gallbladder is distended with a large amount of sludge; however, there is no wall thickening, pericholecystic fluid, or son sign to suggest acute cholecystitis. there is no ascites. the spleen is again enlarged measuring 15 cm. duplex examination of the liver: there is hepatopetal flow within the main, right, and left portal veins as well as normal flow within the main, right, left, and middle hepatic veins. the main, right, and left hepatic arteries maintain brisk arterial upstroke and preserved diastolic flow. the ivc and splenic veins are patent. impression: 1. normal doppler examination of the liver. 2. cirrhosis, splenomegaly, and no significant ascites. 3. new small 2 cm nodule within segment ii of the liver, which is suspicious for malignancy in this patient with underlying cirrhosis. an mri is recommended when the patient is clinically stable. . unilat lower ext veins right 3:29 pm findings: no evidence of deep venous thrombosis identified. compressibility, flow, and augmentation is maintained throughout the right lower extremity. impression: 1. no evidence of deep venous thrombosis identified. brief hospital course: # endocarditis: the patient has valvular mass with typical bacteria () for infective endocarditis and a potential source of bacteremia could be prior left ankle osteomyelitis. he was without significant conduction defect compared to priors. he was without sign of significant valvular compromise or respiratory distress. see echo above showing 1+ mr. , all blood cultures were negative with the exception of one bottle growing coag negative staph, presumably a contaminant. he underwent an mri of his pelvis and right knee as he was complaining of some pain in that area looking for further sites of hematogenous spread which was negative. he was started on nafcillin, which had to be discontinued because the development of ain. vancomycin was restarted per id and he will need a total of an week course, which will be continued at least until he has id follow-up on with dr. . he will need a vancomycin trough level drawn after his third dose of 750 mg iv daily, which is being started upon discharge to rehab. please check biweekly (twice per week) cbc with differential, chem 7 (electrolytes with renal function), alt, ast, total bilirubin, ldh, vancomycin trough, esr, & crp and fax to dr. (id physician at ) at . . # renal failure: consistent with ain as he had wbc casts in his urine. urine na 18, he is not significantly decompensated hepatically, and his bp is not low (as it would be with splancnic vasodilation, thus less likely hepatorenal. has not responded well to fluid or albumin. his nafcillin was thought to be the offending and was thus discontinued as above. pantoprazole was also changed to zantac because pantoprazole has been associated with ain as well. his creatinine peaked at 2.2 and improved to 2.0 upon discharge. upep negative. spep shows polyclonal hypergammaglobulinemia, c3, c4 wnl. contrast agents should be avoided if possible. please check biweekly (twice per week) cbc with differential, chem 7 (electrolytes with renal function), alt, ast, total bilirubin, ldh, vancomycin trough, esr, & crp and fax to dr. (id physician at ) at . . # discitis: outside mri shows what appears to be discitis per radiology, ir agreed. no management was undertaken. serial exams throughout his stay were stable. . # elevated inr: likely from multiple sources including liver disease, poor nutrition, and possibly low level dic as per dic labs. his inr peaked at 3.2. he was given vit k with little effect though the inr improved with time to 1.6 on the day before discharge. . # peripheral vascular disease: appears to have adequate macrovascular flow to feet as gauged by peripheral pulses. continued aspirin. initially held plavix given potential for operative management of discitis; it was restarted and will need to be taken into consideration if he is ever a candidate for surgery. . # anemia: he had evidence of chronic inflammation, renal disease, liver disease, and hemolysis during his stay to account for his anemia. he required 2u prbcs on to . his hct was stable for the last several days in the mid 20s. he will need a cbc drawn biweekly and will need transfusions for symptoms or hct < 23. please fax results of all labs to dr. as per discharge planning. . # cirrhosis: of unknown etiology. minimal etoh history, no other known liver history. there was also a singular nodule which was consistent with hcc per radiographic studies as above. liver was consulted and recommended further outpatient workup with possible biopsy and rfa. hep serologies negative. and ama negative. igg and iga elevated, igm normal. alpha-1 antitrypsin normal, sma negative, hereditary hemachromatosis test pending. nodule in liver consistent with hcc by ct with contrast. afp wnl. he had moderate ascites. an appointment was made for hepatology follow-up as per discharge planning. . # worsening rle edema: no dvt per leni . diuresed well with iv and po lasix. he is being discharged on po lasix, which should be titrated according to his fluid status, renal function, and blood pressure. i/os should be checked daily until a stable regimen is reached. . # decubitus ulcer: wound care involved. see wound care orders for care. . #fen: a calorie cound showed he was taking less than 50% of daily recommended calories. his diet was limited by subjective satiety, pain with sitting up, and difficulty eating when not sitting up. increased po should be encouraged and his diet should be supplemented with ensure/boost. he should be pretreated for pain before being sat up for meals. consideration of a feeding tube was given, but it was decided to continue to try to encourage po. a feeding tube should be considered in the future if he continues to be unable to keep up with caloric demands. . # heel osteomyelitis: likely source of his endocarditis. podiatry followed and felt his heel looked good. see wound care orders for care. . # hamstring tear: likely majority of his leg pain. he was given pain control: lidocaine patch, fentanyl patch, dilaudid po and iv. the iv dilaudid was d/c'd on the day before admission. he should be pretreated with po dilaudid before moving, cleaning. he should at least be out of bed to a chair every day. . # diabetes mellitus type 2: he was maintained on ssi with humalog as well as 10 units glargine qhs. his blood glucose remained in the 100s for several days before discharge. . # hypothyroidism: - continued on home dose thyroxine . #access: piv . #ppx - heparin sub-q for dvt prophylaxis . #code: dnr/dni . #communication: patient and wife medications on admission: medications on transfer: vancomycin 1000 mg iv q12 kefzol 2g iv q8 (start ) aspirin 81 mg daily colace 100 mg dilaudid 1-2 mg q4-6h:prn duragesic patch 75 mcg q 72 hours humalog insulin sliding scale lantus 25 units qhs multivitamin daily niacin cr 500 mg daily plavix 75 mg daily protonix 40 mg daily synthroid 50 mcg daily tylenol mg q6:prn tricor 145 mg daily discharge medications: 1. lab work please check biweekly (twice per week) cbc with differential, chem 7 (electrolytes with renal function), alt, ast, total bilirubin, ldh, vancomycin trough, esr, & crp and fax to dr. (id physician at ) at . 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 3. hexavitamin tablet sig: one (1) cap po daily (daily). 4. niacin 500 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 5. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 6. fenofibrate micronized 145 mg tablet sig: one (1) tablet po daily (). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. polyethylene glycol 3350 100 % powder sig: one (1) gram po daily (daily) as needed for constipation. 12. fentanyl 75 mcg/hr patch 72 hr sig: one (1) patch transdermal q72h (every 72 hours): please apply with other 50mcg patch. 13. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch transdermal every seventy-two (72) hours: please apply with other 75mcg patch. 14. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): keep on for only 12 hours at a time. 12 hours on, 12 hours off. 15. hydromorphone 2 mg tablet sig: 4 to 8 tablets po every six (6) hours as needed for pain: hold for sedation, rr < 12. 16. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 17. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 18. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 19. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 21. insulin glargine 100 unit/ml solution sig: ten (10) units subcutaneous at bedtime. 22. insulin sliding scale sliding scale per attached sheet 23. picc picc care per protocol. non-heparin dependant picc. 24. foley care foley care per protocol. last changed . should be discontinued when scrotal edema decreases. *** addendum **** vancomycin 750 mg iv every 24 hours x 8 weeks. will be adjusted by levels at direction of dr. . do not stop vancomycin until directed by dr. . discharge disposition: extended care facility: hellenic - discharge diagnosis: methicillin-sensitive staph aureus bacteremia with left ankle osteomyelitis, endocarditis acute renal failure secondary to acute interstitial nephritis, stable discharge condition: afebrile, normotensive, comfortable on room air discharge instructions: you were seen at for fevers and endocarditis, for which you were treated with iv antibiotics which will continue for a total course of weeks. you have follow-up with infectious disease specialists on , at which time they will address this and you should be continued on the iv medications until that time. . you were also found to have cirrhosis. the etiology of this is unknown. there is a lesion in your liver that is suspicious for cancer. you have follow-up with the hepatologists as below. . please take your medications as prescribed. please follow-up as below. . you should call your primary care provider or return to the emergency department if you notice fevers/chills greater than 100.5 degrees f, chest pain, shortness of breath, confusion, new numbess/tingling/weakness anywhere in your body, difficulty speaking, or any other symptoms that concern you. followup instructions: please follow up with dr. in infectious disease at on at 9:30 am. call his office at if there is a problem with this appointment. please follow up with your pcp, . , on tuesday, at 2:30 pm. call his office at if there is a problem with this appointment. please follow up with dr. in the liver center on at 2:10 pm. his office is located at (), ; call his office at ( if there is a problem with this appointment. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart diagnoses: anemia, unspecified acute kidney failure, unspecified infection with microorganisms resistant to penicillins bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site pressure ulcer, lower back acute glomerulonephritis with other specified pathological lesion in kidney acute and subacute bacterial endocarditis pressure ulcer, heel other and unspecified coagulation defects unspecified osteomyelitis, ankle and foot other and unspecified disc disorder, unspecified region 

Answer: The patient is high likely exposed to