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: penicillins / sulfa (sulfonamides) attending: chief complaint: fever. major surgical or invasive procedure: on a left internal jugular line was placed. on a picc was placed and the ij was pulled. history of present illness: patient is a 58 year old woman with a history of end-stage ms, who is aphasic at baseline but can communicate through head nods, presents with one day of fever, tachycardia (130s), and mental status changes. she was started on levofloxacin and metronidazole at her nursing home for empiric coverage of pneumonia on . by head nods, she denies chest pain, fevers or chills, pain in her abdomen, nausea, vomiting, vaginal itching or pain. . she was discharged on following admission with similar symptoms (elevated lactate, elevated wbcs, fever, positive ua, urine cultures with proteus, and hypotension) on which she was found to have proteus urosepsis. she was discharged with seven days of meropenem and sent out with a picc line in place. she finished meropenem course four days prior to admission, but picc line was still in place. her only other complaint at that time was pelvic/lower abdominal pain thought to be secondary to peri-ostomy skin irritation and possible slowed gastric motility. ct did not show any evidence of pathology. ppi was increased to . . in the ed, she had a fever of 101, and there was report of frank pus from the catheter. ua was negative. wbc was 14.1, and lactate was initially 2.2. she was admitted to the micu due to increased nursing needs. her vitals were 97.3, 99, 128/49, 17, 99% on 2l nc, 2630/1000. a central line was placed. she was started on merepenem, ceftriaxone, vancomycin empirically for presumed proteus infection. following hydration with five liters normal saline, repeat lactate was 0.9, and hematocrit dropped from 39 to 30.5. blood culture showed enterococcus, with sensitivities pending, so linezolid was added for vre coverage. picc line was pulled and the tip was sent for culture. urine cultures were negative. she had a cxr which showed bibasilar atelectasis and could not rule out an underlying consolidation. abdominal and pelvic ct showed no acute inflammatory process. pelvic us was negative. pelvic swabs are pending. urine and blood cultures are pending. past medical history: -multiple sclerosis, daignosed in . her decline has only been in the past 18 months. she went from fully communicative before to nonverbal now. she was ambulating independently but started using a cane, then a walker, and is now bedbound. -s/p total colectomy + colostomy for "compaction and infection," (at and women hospital) -proteus urosepsis treated with merepenem -urinary tract infection -depression/mood disorder -anxiety -hepatitis c -hepatitis b -optic neuritis -dysphagia social history: lives at nursing home. reported to have a friend in the community serves as her health care proxy. family history: not known, as patient is nonverbal. physical exam: on transfer to medicine: tm 101.5 tc 97.3 bp 122/82 hr 96 rr 20 o2sat 98% 2l nasal canula gen: overweight, very pleasant female lying in bed in slumped position, in nad heent: sclera anicteric, mucous membranes moist, oropharynx clear neck: supple, no jvp, carotid pulses 2+ bilaterally cv: rrr, nl s1 s2, no m/r/g, pmi 5th ics midclavicular line without heaves or thrills chest: poor air movement, crackles at right lung base, no w/r/r abd: midline surgical scar. ileostomy bag on right mid abdomen, g-tube. bs+, soft, diffusely mildly tender to palpation in the midepigastric area, nondistended, no guarding, no rebound, no bruit or masses, ecchymoses on lower abdomen from subcutaneous heparin injections. ext: upper and lower extremities warm and well perfused. 2+ dorsal pulses, right heel erythema consistent with stage i ulcer. small ?necrotic area on r great toe. skin: no rash, bruises, or wounds neuro: a&o, cooperative and coherent, nods to consent, shakes head to disagree. give appropriate answers. cries if frustrated. cn ii grossly intact, as she can tract movement with her eyes. iii, iv, vi intact. v intact to light touch. cnvii intact, capable of big smile. cnviii intact to finger rub bilaterally. gag not tested. tongue midline, with fasciculations. motor is diminished throughout, but she is capable of very slight finger grasp, arm movements, and toe movement. sensation to light touch is intact throughout. pertinent results: labs on admission: wbc-14.1* rbc-3.89* hgb-12.8 hct-39.1 mcv-101* mch-32.9* mchc-32.8 rdw-13.3 plt ct-549* pt-12.5 ptt-31.9 inr(pt)-1.1 esr-90* glucose-106* urean-27* creat-0.4 na-141 k-4.4 cl-102 hco3-30 alt-35 ast-23 ck(cpk)-22* alkphos-75 amylase-164* totbili-0.6 lipase-18 albumin-3.9 calcium-9.9 caltibc-241* vitb12-571 folate-greater th ferritn-170* trf-185* . micro: -toe culture (): 2+pmn. 1+ gm+ cocci. staph coagulase positive. -blood cultures (, , , , ): no growth to date. -catheter tip iv culture (): no significant growth. -vaginal swab culture (): gram stain negative for bacterial vaginosis, 3+ budding yeast with pseudohyphae, yeast vaginitis culture pending. chlamydia trachomatis nucleic acid probe negative. gc nucleic acid probe negative. -urine culture (): negative. -blood culture (): enterococcus faecalis. sensitive to ampicillin, penicillin, and vancomycin. . imaging: toe xray (): focal area of osteopenia in the first metatarsal head, cannot rule out osteomyelitis, clinical correlation is requested. . transvaginal us : normal pelvic ultrasound, no free pelvic fluid or collection; small nabothian cyst of the cervix . echo : the left atrium is mildly dilated. left ventricular wall thicknesses are normal. 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 appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. no vegetation seen (cannot exclude). . ekg : sinus tachycardia. indeterminate axis. late precordial qrs transition. findings are non-specific but clinical correlation is suggested for possible chronic pulmonary disease. since the previous tracing of no significant change. . ct abd and pelvis w/contrast : 1. persistent right lower lobe consolidative opacity, which could represent atelectasis, although pneumonia is also possible. 2. similar appearance of stones and sludge within the gallbladder, including a partly calcified stone in the gallbladder neck. if cholecystitis is suspected clinically as a cause for fever, ultrasound could be helpful to evaluate further. no inflammatory change is seen by ct, however. 3. status post colectomy with ileostomy. 4. fluid in the vagina. . cxr : right lower lobe atelectasis and persistent right hemidiaphragm elevation. left lower lobe atelectasis and effusion. brief hospital course: assessment and plan: 58 year old female with a history of multiple sclerosis and aphasia, presents with one day history of fever, tachycardia, mental status changes, and abdominal tenderness following recent admission for urosepsis, treated with meropenem and picc line left in place four days after completed course. . # fever: on admission, there was frank pus from her picc catheter. wbc was elevated at 14.1. she was started on vancomycin and ceftriaxone, although urinalysis did not indicate urinary tract infection. chest xray was not significantly changed from her prior visit, which was thought to represent atelectasis, though could not rule out pneumonia. she has persistent lower abdominal and pelvic pain, and on ct was noted to have intermediate density fluid in vagina and sludge and gallbladder neck stone. ast/alt/ap/tbili were all within normal. pelvic ultrasound was negative, examination and cultures consistent with yeast, and she was treated with one dose of fluconazole, and cultures for chlamydia and gonorrhea were negative. blood cultures were positive for enterococcus, initially empirically covered for vancomycin resistant enterococcus. she was initially started on linezolid for two days, and was switched to vancomycin when cultures showed sensitive to ampicillin, penicillin, and vancomycin. she has a penicillin allergy that causes limited rash, however per ptatient may also have had shortness of breath with penicillin in past. tte on did not reveal any vegetations. tee was considered, but bacteremia was thought most likely to be transient, as no leaflet thickening on tte. catheter tip cultures were negative. surveillance cultures have been ordered each day and continue to be negative since first set of enterococcus. patient had a lesion (necrotic versus cellulitic) on 1st right metatarsal, so id recommended a toe radiograph, which shows an area of focal osteopenia, and no clear osteomyelitis. swabs of the wound were positive for coagulase positive staphylococcus and bacitracin ointment was recommended for four days. for the positive blood cultures, id recommended vancomycin for two weeks only. a picc was placed on day of discharge so patient can be discharged to her home care facility for the remainder of her course of vancomycin. please be sure to pull her picc line immediately after finishing the final dose of vancomycin so as to decrease further risk of infection. wbc continued to trend downwards for duration of admission, and patient remained afebrile. . # mental status change: patient presented with changes in mental status, likely related to the onset of fever, pain, and leukocytosis. there is no history or evidence of trauma, stroke, or hypoperfusion. mental status changes have resolved, and patient is engaging appropriately, nodding in response to questions. . # abdominal pain: patient has mild tenderness to palpation diffusely in her abdomen, likely chronic in nature. on her last admission she had abdominal pain, and two cts of the abdomen and pelvis were negative for obstruction. her lfts were unremarkable, and c diff was negative on two cultures. skin breakdown around her ostomy site was noted and thought to be contributing to her pain. she had been started on reglan with the thought that gastric motility and ppi increased to for gastroesophageal reflux disease. on this admission, ct shows gallstones in neck and some sludge, but no elevation in biliary or liver labs to indicate obstruction. pelvic exam was negative, with positive cultures for yeast and she was given one dose of fluconazole. transvaginal us was negative. no changes in ostomy output. she initially continued to groan and endorse abdominal pain, with diffuse mild tenderness to palpation throughout abdomen. on she was much more comfortable and had stopped groaning. on she no longer complained of abdominal pain. . # heel and toe wounds: patient has erythematous patch on back of right ankle, consistent with stage 1 ulcer. podiatry was consulted and recommended cleaning with bacitracin dressings. id was concerned for right first metacarpal toe lesion, so ordered toe scan, as above, which showed focal area of osteopenia; no mri was thought necessary. the patient should follow up with podiatry as an outpatient in about two weeks after discharge. . # multiple sclerosis: we contineudthe patient's usual outpatient neurologic medications including valproic acid, copaxone and baclofen. . # depression: patient has depression at baseline. we continued her home dose of amitriptyline without event. . # fen: at baseline, patient is fed through g-tube s/p colectomy . she was aggressively rehydrated in the ed and had stable systolic blood pressures in the 110-120s. we continued her usual tube feeds of probalance full strength at 55cc/hr. she is otherwise npo. we continued her calcium and vitamin d as well as her daily multivitamin. . # access: l picc placed on day of discharge. this should be pulled immediately after last dose of vancomycin is finished. . # code: confirmed dnr/dni status. . # contacts: pcp . ; hcp is medications on admission: medications on admission: -amitriptyline 50 mg hs -calcium carbonate 500 mg tid -cholecalciferol (vitamin d3) 400 unit daily -fluticasone 50 mcg/actuation 2 spray nasal daily -multivitamin 1 cap daily -valproate sodium 250 mg/5 ml 13 ml q12h -docusate sodium 50 mg/5 ml 10 ml -gabapentin 250 mg/5 ml 300 mg tid -metoprolol tartrate 12.5 mg tid -acetaminophen 650 mg q6h -baclofen 5 mg hs -oxycodone 5 mg q6h prn -prilosec 20 mg -glatiramer 20 mg sq daily -metoclopramide 10 mg 4 times daily . medications on transfer from micu: -amytriptyline 50mg po hs -baclofen 5mg po hs -calcium carbonate 500mg po tid -docusate 100mg po bid -fluconazole 150mg po one dose 2/13 -gabapentin 300mg po q8h -glatiramer 20mg sc daily -heparin 5000 sc tid -linezolid 600mg iv q12h -metoprolol 12.5mg po tid -meropenem 500mg iv once -miconazole powder 2% 1 application tp prn -mvi 5ml po daily -oxycodone immediate release 5mg po q4-6h prn -pantoprazole 40mg iv q24h -potassium chloride 40meq/100ml iv once -vitamin d 400 units po daily discharge medications: 1. amitriptyline 50 mg tablet sig: one (1) tablet po hs (at bedtime). 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po once a day. 4. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) sprays nasal once a day. 5. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 6. valproate sodium 250 mg/5 ml syrup sig: thirteen (13) ml po every twelve (12) hours. 7. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 8. gabapentin 250 mg/5 ml solution sig: three hundred (300) mg po three times a day. 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 10. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours. 11. baclofen 10 mg tablet sig: 0.5 tablet po hs (at bedtime). 12. oxycodone 5 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 13. glatiramer 20 mg kit sig: one (1) kit subcutaneous daily (). 14. metoclopramide 10 mg tablet sig: one (1) tablet po four times a day. tablet(s) 15. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 12h (every 12 hours) for 14 doses: continue for seven days following discharge. **remove picc following last dose of vancomycin.**. disp:*14 bags* refills:*0* 16. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 17. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed: please flush each picc lumen with 10cc ns followed by 1ml heparin per shift and prn. 18. tylenol 325 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for fever or pain. discharge disposition: extended care facility: - discharge diagnosis: enterococcus bacteremia. discharge condition: stable. discharge instructions: -you were admitted for fever, tachycardia, and change in mental status, noticed at your nursing home. in the hospital, blood cultures grew enterococcus. the picc line was removed and an internal jugular line was placed. you have been started on vancomycin, and will be discharged with a new picc line for a total of two weeks of antibiotic coverage. -***the picc line should be pulled on following your last dose of vancomycin.*** -you were found to have the beginnings of an ulcer on the back of your right heel and a necrotic wound on your right first metatarsal. podiatry recommended using bacitracin and wrapping the wounds. -you should schedule a follow up appointment with podiatry in two weeks (see below). -you should follow up with your primary care doctor, dr. , in the next two weeks (see below). if you have fever, shortness of breath or other concerning symptoms please call dr. or come to the emergency room. followup instructions: -***the picc line should be pulled on following your last dose of vancomycin.*** -you should schedule an appointment with dr. in the next two weeks. -you should schedule a follow up appointment with podiatry in the next two weeks. procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances nonexcisional debridement of wound, infection or burn debridement of nail, nail bed, or nail fold injection or infusion of oxazolidinone class of antibiotics diagnoses: chronic hepatitis c without mention of hepatic coma sepsis ulcer of other part of foot infection and inflammatory reaction due to other vascular device, implant, and graft pressure ulcer, heel multiple sclerosis streptococcal septicemia chronic viral hepatitis b without mention of hepatic coma without mention of hepatitis delta ileostomy status gastrostomy status cellulitis and abscess of toe, unspecified 

Answer: The patient is high likely exposed to