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: no known allergies / adverse drug reactions attending: chief complaint: fever, ams major surgical or invasive procedure: right femoral line placement left tunneled catheter removal left arterial line placed history of present illness: 61 male with history of seizure disorder, nonischemic cardiomyopathy ef 20-30%, esrd on hd (t/th/sat, last session on saturday), hepatitis b, cad, cva, recent admission for line bacteremia given vanco for 2 week course, who was at his rehab center and found to be febrile with altered mental status and hypoglycemia. his sugars there were in the 30s and he was given oral glucose which improved his finger stick to 156. his baseline mental status is a+0x3 but today he was a+o x2. . pt had recent admission in for staph epidermidis and cons bacteremia, thought to be from tunnel line (tunnel tip grew cons). at that time, tunnel line was changed (, fluro guided tunnel line, exchanged over wire). pt was given vancomycin for 2 week course, dosed per hd protocol. . in the ed inital vitals were, t 102.2 hr 105 bp 94/44 rr 18 pox 98% 2l. tm 104. pt noted to have pus coming out of his tunnel line on left. his temp spiked at 104, sbp initialy 160s. tunnel line culture was sent off. aaox2 (not to location). patient was given 4l ns, maps dropped to the low 60s, placed femoral line (goal was to preserve other sites sinec pt likely currently bactermic and will likely need new line), started levophed infusion 0.06 (bp 94/45). for fever of 104, given rectal tylenol 650mg, linezolid 600mg, zosyn 4.5 (not given vanco bc history of vre). cultures were obtained including blood, urine, hd catheter swab. labs were significant for cbc wbc 11.9, hgb 9.4, hct 31, plt 366. n 88%. inr 1.3, ptt 34. phos low at 1.6, mg 2, ca 9.7. lytes revealed ua: large euks, blood, 300+ protein, sh 1013, ph 6.5. na 135, k 5.1, cl 94, bicarb 25, bun 33, cr 8.2, gluc 107. ag was 16. lactate 2.3. abg: ph 7.43, co2 41, o2 58, hco3 28 cxr showed: no signs of pneumonia, mildly increased pulm vascular pressures. access includes 18g right and left forearm and right neck. femoral line and tunnel line. most recent vitals: 101 80/44 18 82 96% 2lnc . on arrival to the icu, pt is a+o x3, states he has a doctorate in history and music. he is at times sleepy, and at times very sharp and able to answer questions such as the details of his phd. denies any pain anywhere, no cough, no abd pain, last bm yesterday, no diarrhea, states he has been admitted several times for recurrent tunnel line infections. . review of systems: (+) per hpi (-) denies recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - seizure disorder since mid 's after starting dialysis - mssa hd line infection with septic lung emboli with left pleural effusion - h/o hepatitis b, treated - non-ischemic cardiomyopathy, last ef 20-30% - mi per pt - cva per pt (?residual le weakness) - esrd on hemodialysis htn. edw 80 kg as of . - multiple thrombectomies in lue and r thigh av fistula - graft excision for infected thigh graft - hungry bone syndrome status post parathyroidectomy - pituitary mass - anemia of chronic disease - s/p peg tube placement - admission to micu in for seizure and hypotension - swab positive for mrsa and vre at left groin site in and mrsa positive from same site - admission for staph epidermidis bacteremia and cons bacteremia sp vanco x 2 weeks -: mssa and vre bacteremia -mssa and social history: retired piano and organ teacher. has 2 phds (history and music) and prefers to be called "dr. ." walks with a walker at baseline. never smoker, no other drug use. drinks 1 drink/week. has 2 sisters that live out of state, son died few years ago ("was shot to death"). family history: father with dm, mother died at age 41 of renal failure physical exam: admission physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: anterior lungs are clear bilaterally cv: regular rate and rhythm, normal s1 + s2, systolic murmur left sternal border, no rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley with scant dark urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. slightly decreased skin turgor. right knee with warm patellar joint, ballotable. neuro: cn 2-12 intact, sensation throughout, stregnth throughout, small pinpoint pupils, eom intact, a+o x3. pertinent results: labs: on admission: 09:00am blood wbc-11.9*# rbc-3.63* hgb-9.4* hct-30.9* mcv-85 mch-25.8* mchc-30.4* rdw-16.0* plt ct-366 09:00am blood neuts-88.0* lymphs-6.1* monos-3.1 eos-2.7 baso-0.1 09:00am blood pt-14.0* ptt-34.0 inr(pt)-1.3* 09:00am blood glucose-107* urean-33* creat-8.2*# na-135 k-5.1 cl-94* hco3-25 angap-21* 09:00am blood calcium-9.7 phos-1.6*# mg-2.0 02:59pm blood tsh-0.45 02:59pm blood cortsol-40.3* 02:58am blood cortsol-25.6* 09:00am blood digoxin-1.5 09:11am blood po2-58* pco2-41 ph-7.43 caltco2-28 base xs-2 09:11am blood glucose-102 lactate-2.3* k-5.1 calhco3-27 micro: blood cx , 25, 26, 29: no growth to date blood cx : mrsa femoral cvl tip : no growth to date hd catheter tip : mrsa joint fluid: 12:00; culture showed no growth. wbc rbc polys lymphs monos 81 17 2 wound swab (from prior hd cath site): mrsa urine cx: : no growth studies: radiology chest (portable ap) mild cephalization which could reflect mild pulmonary venous congestion. cardiovascular echo the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 55%) with subtle basal inferior hypokinesis. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. compared with the prior study (images reviewed) of , the lvef has improved. radiology knee 2 view portable ri there are degenerative changes with narrowing of the lateral compartment which causes valgus angulation at the knee. there is spurring at the inferior pole of the patella. there is no joint effusion. there are no focal lytic or blastic lesions. there is some soft tissue swelling. radiology chest (portable ap) hd catheter has been removed. there is no evident pneumothorax. if any there is a small right pleural effusion. cardiac size is top normal. the aorta is tortuous. the chin of the patient obscures the right apex. there is mild vascular congestion. there are no new abnormalities from . there are low lung volumes. widened mediastinum and deviation of the trachea towards the right is due to enlarged thyroid gland. multiple left rib fractures are noted. brief hospital course: brief hospital course: this is 61 male with history of seizure disorder, nonischemic cardiomyopathy ef 20-30%, esrd on hd (t/th/sat, last session saturday), hepatitis b, cad, cva, several admissions in the past for tunnel associated mssa/cons/vre bacteremia, recent admission 1 month ago for staph epidermidis and cons line bacteremia given vanco for 2 week course, who presented with mrsa bacteremia likely due to an infected tunnel line. . active issues septic shock: the patient persented with fever (tm 104), leukocytosis (wbc 12), tachycardia (hr 100s), lactate 2.3, mental status change, and bp 94/44 on low dose levophed and after 4l, consistent with septic shock. methicillin resistant staph aureus grew from the blood culture bottles, swab of the catheter and culture of the tip of the catheter line. pus was noted surrounding the catheter site which was evaluated by general surgery and no i/d indicated. his urine culture revealed no growth despite large amount of leukocytes. his presenting chest xray was clear and joint fluid analysis of his right knee was not consistent with septic arthritis. a tte demonstrated no evidence of vegetations. a tee was deferred given it would not change antibiotic duration. he briefly required pressor support with levophed via a femoral line placed in the ed. he was initially started on linezolid which was discontinued in favor of vancomycin and zosyn in the intensive care unit which were narrowed to vancomycin alone when culture data was available. his hd was line was removed and he hd was deferred for 1 week before a temporary femoral line was placed. surveillance blood cultures were all negative following his admission cultures on . duration of therapy 6 weeks () with vancomycin to be given with hd. a tunneled right subclavian line was placed prior to discharge. . esrd: t/th/sat. last hd prior to admission was 2 days pta, on saturday. hd was deferred for as long as possible, to allow for a line holiday given segnificant bacteremia and sepsis. patient was monitored on telemetry, electrolytes checked daily, small boluses of fluid given for hypotension. hd cath pulled . line was replaced on , w/ hd on , now back on prior tu/th/sat schedule. . altered mental status: patient is significantly altered from baseline. initially, ams felt to be due to hypoglycemia. likely multifactorial-- septic shock, uremia. per patient??????s family, his mental status has been declining for >1 year. neuro exam non focal. patient had one witnessed seizure on the day of hd (5 days into admission), and it was discovered that he had been under dosed on his keppra during the admission. it is possible that he has been having seizures during this time that have been affecting his ms, however, his postictal state is not similar to his mental status throughout the admission. mental status continued to improved. rpr negative. b12 and folate wnl. tsh wnl. head ct in demonstrated expected expected age-related changes. consider neurocognitive testing in the outpatient setting. . hypoglycemia: likely acute infectious state. can also see in renal failure (because insulin cleared by kidneys), hypopit (pt has known pituitary mass), adrenal insuf (had normal cortisol am level check on prior admission), insulinoma. most likely etiology is sepsis. tsh wnl. patient's blood glucose wnl after 1 day into admission. . seizure disorder: patient is on oxcarbazepine and keppra as an outpatient. patient was underdosed keppra during his hd vacation this admission. he experienced a brief localized seizure consisting of 1 minute of facial twitching 5 days into admission. pt was apparently on the incorrect seizure medication, which was per his prior d/c summary and outside facility list (was ~ of his appropriate dose neuro note). pt??????s prior seizures were more generalized, last documented in , attributed to medication non-compliance. neurology was consulted and pt was restarted on keppra 500 tid plus 500 mg dose after hd, and oxcarbazepine 300 mg tid plus 300 mg dose after hd. pt apparently tends to have seizures after hd. pt states that he typically has a small facial seizure every few months. pt did not have any further seizures during his hospitalization. . anion gap metabolic acid: likely lactic acidosis and renal failure. gap closed as patient restarted on hd 5 days into admission. . cad/chf: mild pulm edema on cxr, however on exam pt appears mildly volume down with some decreased skin turgor. pt given several liters of ivf in setting of septic shock. he is at risk for pulmonary edema so will trend his o2 requirement and exam closely. hd was restarted 5 days into admission, which will manage volume status. continued home simvastatin and asa, and digoxin dosed according to hd. . anemia: hct baseline 27-30. hct currently 31, at baseline. likely multifactorial: anemia esrd and anemia of chronic disease. he was given epoeitin in dialysis. . inr 1.3: likely poor nutrition, recent antibiotics. no diarrhea. inr trended. he was given vitamin k prior to discharge . hypophosphotemia: phos 1.9 on admission (repleted), lower then expected given renal failure. pt is sp parathyroidectomy. differential includes poor nutrition, osetomalacia, diuretics, hyper-parathyropidism, hyperthyroidism, recovery from starvation, steroids. baseline phos is usualy . repeat phos levels remained wnl. tsh wnl, pth high. . right knee pain. pt was complaining about knee effusion, which felt warm and was tapped by orthopedic service. fluid showed 200 wbc, 1625 rbc, 81% polys 17% lymphs, no organisms on gram stain, no crystals. pt was treated with analgesics with improvement in his pain. . transitional issues - vancomycin for 6 weeks (last date ) - consider neurocognitive testing medications on admission: 1. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 2. calcium acetate 667 mg capsule sig: four (4) capsule po tid w/meals (3 times a day with meals). 3. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. gabapentin 100 mg capsule sig: two (2) capsule po daily (daily). 6. levetiracetam 500 mg tablet sig: one (1) tablet po 3x/week (tu,th,sa): extra dose to be given on dialysis days after dialysis. 7. levetiracetam 500 mg tablet sig: one (1) tablet po tid (3 times a day). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. oxcarbazepine 300 mg tablet sig: one (1) tablet po three times a day. 10. oxcarbazepine 300 mg tablet sig: one (1) tablet po three times a week (tues, thurs, sat): extra dose to be given on dialysis days after dialysis. 11. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 12. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 13. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain: do not exceed 4 grams in 24 hours. 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 16. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. 17. senna 8.6 mg capsule sig: one (1) capsule po at bedtime: hold for loose stools; pt may refuse. 18. chlorhexidine gluconate 4 % liquid sig: one (1) topical times each week. 19. sarna anti-itch 0.5-0.5 % lotion sig: one (1) topical once a day: apply liberally to skin on hands, feet 20. vancomycin in d5w 1 gram/200 ml piggyback sig: as directed intravenous hd protocol (hd protochol): to be dosed based on trough and given on hemodialysis; continue until . 21. oxycodone 5 mg tablet sig: one (1) tablet po every twelve (12) hours as needed for pain. discharge medications: 1. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 2. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 100 mg capsule sig: two (2) capsule po once a day. 5. levetiracetam 500 mg tablet sig: one (1) tablet po tid (3 times a day). 6. levetiracetam 500 mg tablet sig: one (1) tablet po hd days (). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 8. oxcarbazepine 150 mg tablet sig: two (2) tablet po tid (3 times a day). 9. oxcarbazepine 150 mg tablet sig: two (2) tablet po on hd day (). 10. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 11. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 12. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 13. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. 14. senna 8.6 mg capsule sig: one (1) capsule po once a day as needed for constipation. 15. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical daily (daily). 16. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous with hd for 1 doses: to be dosed based on trough and given on hemodialysis days. (duration 6 weeks, last day ). disp:*qs * refills:*0* 17. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: 1. methicillin resistant staphylococcus aureus bactermia 2. end stage renal disease discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , . you were admitted for a fever and found to have another infection in your blood likely related to your hemodialysis line. your tunneled catheter was removed and dialysis was stopped for 1 week. a temporary catheter was then placed in your groin before a new tunneled catheter could be placed in your right subclavian site. you will need to continue antibiotics for a total of 6 weeks. . the following changes were made to your medication list: 1. continue vancomycin with hemodialysis for 6 weeks (last day ) 2. stop ferrous sulfate 3. hold sevelamer until otherwise directed 4. hold calcium acetate until otherwise directed . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow-up with the physicians at your facility and your outpatient nephrologists. procedure: hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis arthrocentesis injection or infusion of oxazolidinone class of antibiotics removal of other device from thorax hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis arthrocentesis injection or infusion of oxazolidinone class of antibiotics removal of other device from thorax diagnoses: other primary cardiomyopathies acidosis anemia in chronic kidney disease end stage renal disease renal dialysis status congestive heart failure, unspecified acquired coagulation factor deficiency severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease disorders of phosphorus metabolism septic shock old myocardial infarction kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy methicillin resistant staphylococcus aureus septicemia effusion of joint, lower leg hypoglycemia, unspecified bloodstream infection due to central venous catheter 

Answer: The patient is high likely exposed to