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: demerol / codeine attending: chief complaint: back pain major surgical or invasive procedure: laminectomy, fusion l2-l4 partial vertebrectomy, fusion l2-l3. history of present illness: 75 year-old female with atrial fibrillation s/p ablation, insulin-dependent diabetes mellitus, hypertension, spinal stenosis admitted to ortho spine for lumbar osteomyelitis, discitis, and phlegmon. prior to admission patient was being treated with iv antibotics per recommendation of ortho spine. given persistent pain and concern for worsening infection, she was taken to or this hospital course. she is currently post-op day 2 for laminectomy, fusion l2-l4 and post-op day 4 for partial vertebrectomy, fusion l2-l3. post-op course was complicated by hypotension requiring pressors; pressors were weaned and she was transferred out of sicu to cc6 on . while there she became overnight to rr of 30. she improved slightly in the morning but continued to have elevated rr. she remained hemodynamically stable. she was found to be in (creatinine 1.4, baseline 0.7) and oliguric so she was transferred to medicine for further management. . prior to transfer, urine lytes showed pre-renal picture so patient was continued on iv fluids. she received 11l of iv fluids but only put out 661ml. cxr showed low lung volumes possibly due to increased abdominal pressure so she was given a suppository (no bm since ). patient reports that she "feels good" at this time. past medical history: past medical history: atrial fibrillation s/p ablation, not on coumadin iron-deficiency anemia gastritis per egd, insulin-dependent diabetes mellitus c/b neuropathy, retinopathy lumbar stenosis, s/p l5-s1 laminectomy (age 40) hypertension hyperlipidemia djd tremor steatohepatitis depression past surgical history: cataract surgery carpal tunnel release bilaterally tonsillectomy appendectomy cholecystectomy social history: patient currently lives in a house in , mass. she lives with her husband. she is now retired but formerly worked in medical records at hospital. she denies etoh, tobacco, and other drugs. mrs. reports attempting to maintain a diabetic diet, but admits to not being as good about it as she should be. she reports exercising by doing chores around the house. family history: diabetes ii physical exam: general: woman in mild distress. anasarca heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . jvp is not elevated lungs: ctab, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: proximal dependent edema noted but mild. no distal edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. + reflexes, equal bl. normal coordination. gait assessment deferred psych: listens and responds to questions appropriately, pleasant pertinent results: 03:40pm blood wbc-8.5 rbc-4.38 hgb-10.9* hct-35.8* mcv-82# mch-25.0* mchc-30.5* rdw-18.3* plt ct-342 08:51pm blood wbc-17.4*# rbc-3.55* hgb-9.3* hct-29.0* mcv-82 mch-26.3* mchc-32.2 rdw-18.2* plt ct-377 03:03am blood wbc-12.5* rbc-3.15* hgb-8.2* hct-26.0* mcv-83 mch-25.9* mchc-31.4 rdw-18.3* plt ct-290 09:30am blood wbc-15.7* rbc-3.10* hgb-8.0* hct-25.6* mcv-83 mch-25.8* mchc-31.1 rdw-18.5* plt ct-237 12:25pm blood hct-25.5* 07:01pm blood wbc-13.6* rbc-3.16* hgb-8.8* hct-26.2* mcv-83 mch-27.9 mchc-33.6 rdw-17.7* plt ct-197 02:22am blood wbc-18.8* rbc-3.55* hgb-10.2* hct-30.4* mcv-86 mch-28.8 mchc-33.6 rdw-17.3* plt ct-245 03:27am blood wbc-11.0 rbc-3.16* hgb-9.0* hct-26.9* mcv-85 mch-28.5 mchc-33.4 rdw-17.7* plt ct-196 09:05am blood wbc-11.2* rbc-3.31* hgb-9.3* hct-27.6* mcv-84 mch-28.0 mchc-33.5 rdw-17.9* plt ct-231 05:10pm blood wbc-11.2* rbc-3.60* hgb-10.0* hct-31.4* mcv-87 mch-27.7 mchc-31.7 rdw-17.7* plt ct-261 05:10am blood wbc-12.9* rbc-3.49* hgb-10.0* hct-30.4* mcv-87 mch-28.7 mchc-32.9 rdw-17.6* plt ct-246 07:30am blood wbc-9.5 rbc-3.67* hgb-10.5* hct-32.3* mcv-88 mch-28.5 mchc-32.4 rdw-17.6* plt ct-274 09:10am blood wbc-12.8* rbc-4.07* hgb-11.2* hct-35.1* mcv-86 mch-27.6 mchc-32.0 rdw-17.7* plt ct-362 09:59am blood pt-20.2* ptt-33.6 inr(pt)-1.9* 05:10pm blood pt-19.4* ptt-34.1 inr(pt)-1.8* 05:10am blood pt-17.8* ptt-33.8 inr(pt)-1.6* 07:30am blood pt-19.0* ptt-32.4 inr(pt)-1.7* 09:10am blood pt-18.9* ptt-32.3 inr(pt)-1.7* 09:10am blood plt ct-362 03:40pm blood esr-30* 03:40pm blood glucose-182* urean-8 creat-0.7 na-142 k-4.7 cl-103 hco3-31 angap-13 08:51pm blood glucose-177* urean-6 creat-0.5 na-140 k-4.2 cl-109* hco3-27 angap-8 03:03am blood glucose-258* urean-8 creat-0.7 na-138 k-4.6 cl-105 hco3-26 angap-12 03:00pm blood glucose-231* urean-13 creat-1.2* na-137 k-4.8 cl-106 hco3-24 angap-12 02:22am blood glucose-189* urean-17 creat-1.3* na-137 k-4.3 cl-108 hco3-21* angap-12 01:44pm blood glucose-180* urean-20 creat-1.4* na-136 k-4.2 cl-107 hco3-22 angap-11 03:27am blood glucose-197* urean-23* creat-1.4* na-136 k-4.1 cl-108 hco3-20* angap-12 09:05am blood glucose-139* urean-22* creat-1.4* na-138 k-3.9 cl-109* hco3-23 angap-10 05:10pm blood glucose-143* urean-23* creat-1.4* na-140 k-4.1 cl-110* hco3-23 angap-11 05:10am blood glucose-151* urean-25* creat-1.3* na-138 k-4.0 cl-108 hco3-21* angap-13 07:30am blood glucose-141* urean-23* creat-1.3* na-140 k-3.5 cl-109* hco3-22 angap-13 09:10am blood glucose-204* urean-21* creat-1.2* na-140 k-3.5 cl-109* hco3-19* angap-16 09:05am blood ck(cpk)-71 05:10pm blood alt-15 ast-17 ld(ldh)-178 ck(cpk)-56 alkphos-114 totbili-0.9 09:05am blood ck-mb-2 ctropnt-0.02* 05:10pm blood ck-mb-notdone ctropnt-0.02* 08:51pm blood calcium-7.9* phos-4.4 mg-1.1* 09:10am blood calcium-8.2* phos-3.2 mg-1.5* 01:44pm blood caltibc-131* ferritn-234* trf-101* 03:40pm blood crp-1.4 06:59pm blood vanco-22.6* 05:43am blood vanco-19.6 09:05am blood vanco-25.4* 09:10am blood vanco-26.0* 05:37pm blood type-art po2-88 pco2-32* ph-7.41 caltco2-21 base xs--2 05:25pm blood glucose-160* lactate-1.3 na-135 k-3.6 cl-101 10:45am blood glucose-191* lactate-2.1* na-130* k-4.5 cl-105 11:37am blood glucose-198* lactate-2.9* na-132* k-4.4 cl-102 10:21pm blood lactate-2.2* 05:37pm blood lactate-1.0 05:25pm blood freeca-1.10* 11:37am blood freeca-0.98* l-spine films (intra-operative)- lumbar anterior spine fusion l1 through l4, seven portable intraoperative views of the lumbar spine: six lateral, one ap. films dated at 16:15 p.m. presented now for official interpretation. successive lateral views show background osteopenia, degenerative change, and multilevel listhesis. for the purposes of the this report, there is grade i anterolisthesis at l4/5. there is sclerosis at l2 which raises the question of osteomyelitis. views show steps during placement of a vertical side bar and screws into the presumptive l2 and l3 vertebral bodies and an intervertebral fusion device at l2-3, with apparent partial vertebrectomy of the infeiror l2 vertebral body. the superior screw is positioned near the superior endplate of l2, although its exact position is difficult to confirm due to lumbar lordosis on the ap view. hardware is otherwise in nominal alignment. dense aortic calcification and surgical clips are noted. impression: intraoperative radiographs demonstrating posterior fusion from l2 through l4. there is also grade 2 anterolisthesis of l4 with respect to l5, unchanged to prior radiograph. for further details, please consult the operative report. chest x-ray ()- impression: persistent left lower lobe collapse with left-sided pleural effusion. renal u/s ()- impression: 1. no hydronephrosis of the kidneys. 2. a small to moderate amount of ascites is identified. clinical correlation is advised to determine the etiology of the ascites. 3. the visualized portion of the liver has a mildly nodular outline, which may indicate cirrhosis or other chronic liver disease. correlation with history and serum liver function tests is advised. abdominal x-ray ()- impression: no obstruction or ileus seen. echo ()- the left atrium is normal in size. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional left ventricular systolic dysfunction with basal to mid anteroseptum akinesis, anterior hypokinesis, and mid to distal inferior hypokinesis. overall left ventricular systolic function is moderately depressed (lvef= 35-40 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the anterior and anteroseptal left ventricular systolic dysfunction is new. subtle inferior wall hypokinesis can be appreciated in the prior study, but is worsened in the current study. brief hospital course: 75 year old female with severe spinal stenosis and chronic low back pain who had two prior hospital admissions as well as long term iv abx for concern for vertebral osteomyelitis with a suspected source being a previous steroid injection. at rehab the patient seemed to be clinically improving until she developed worsening back pain with an mri performed that was concerning for worsening of her osteomyeleitis of the lumbar spine. on pt was admitted to the orthopaedic spine service for progression of infection despite abx management and with a partial vertebrectomy of l2 and l3, fusion l2-l3, instrumentation l2-l3 (rod and screw in place), autograft bone morphogenic protein allograft, and interbody spacer performed. intraoperatively, the pt had signs of osteomyelitis at l2 and l3. on , a total laminectomy of l2/l3/l4, fusion l2-l4, segmental instrumentation of l2-l4, and implantation of autograft was performed. or cultures had 1+ poly on gram stain of tissue and cx are ngsf. on the pt was noted to be hypotensive with decreased urine output in the pacu. pressors were started and the patient was admitted to the sicu for closer monitoring. while in the sicu patient was weaned off pressors and was found to have cr of 1.4 with continued low urine output. medicine was consulted on and she was transferred to the medicine service for further evaluation of her kidney function. floor course: #. acute kidney injury/oliguria- creatinine on transfer was 1.4 (baseline is 0.7). patient was given iv fluids prior to transfer due to concern for pre-renal etiology (urine sodium < 10, recent hypotension). another concern was ischemic atn. urine was evaluated under the microscope but showed now signs of atn at that time. she continued to have minimal uop (661ml in 24 hrs). renal u/s showed no hydronephrosis and urine culture was negative. her fluids were discontinued given positive fluid balance and she was given lasix 20mg iv x 1 in the evening. she responded well overnight and continued to do so throughout her stay. her creatinine trended down (was 1.2 on discharge). patient was discharged on lasix 40mg po daily. we ask that her physician this dose while at rehab. #. tachypnea- patient found to be tachypneic after procedure up to 36. she was down to mid to high 20's on transfer to medicine and required 2l nc o2 but satted well. she was breathing in a manner she has not done before (open mouth, no signs of gasping for air). an abg was done and did not show any signs of respiratory compromise (ph of 7.41, pco2 32, po2 88). repeat chest x-ray showed low lung volumes with possible left sided effusion. another concern was intra-operative mi with resulting new wall-motion abnormality leading to poor forward flow. cardiac enzymes were negative x 2. echo performed on showed decreased systolic function compared to previous study. patient was weaned off oxygen and did very well on ra. she continued to diurese well on lasix. she was discharged on lasix 40mg po daily given her cardiac dysfunction. patient has follow-up with her cardiologist, dr. on at 1:45pm. we ask that he evalutes patients cardiac function at this visit. upon discharge, she was no longer tachypenic (rr- 16) and was satting comfortably well on room air. #. lumbar osteomyelitis- see above for more details. patient continued on vancomycin iv but given supratherapeutic levels, her dose was decreased intially to 750mg q12hr then to 1250mg q24hr. her wbc count trended down after procedure and patient remained afebrile while on the floor. ortho spine followed and patient did not show any signs of neurologic compromise. cultures did not grow any microorganisms. upon discharge, patient remains afebrile and comfortable. #. atrial fibrillation- patient is rate-controlled on atenolol 100mg daily. given recent acute kidney injury, we switched her to metoprolol tartrate (atenolol cleared by kidney). we noted that the patient was not anticoagulated with coumadin despite her history of atrial fibrillation. we discussed this with her pcp who says she has never been anticoagulated and he referred us to her outpatient cardiologist. we ask that dr. evaluate her anticoagulation options, if she requires it, when he sees her on at 1:40pm. she was discharged with metoprolol tartrate 50mg po bid. # uti- patient's ua and culture did not show any signs of infections. patient's cipro was discontinued. she remained afebrile while here. #. htn- patient was continued on home bp medications except her enalapril was held given her . enalapril was held on discharge given that creatinine was not at baseline. we ask that her outpatient physicians consider resuming her ace-i once creatinine is stable. # iron deficiency anemia- patient received 5u prbcs prior to transfer to medicine. patient continued on iron supplementation. hct on transfer 31.4 and increased to 35.1 on discharge. she did not require any additional transfusions while here. # c. diff- continued on metronidazole 500mg iv q8hr for duration of course of vancomycin (plus an additional 5 days) #. iddm- patient continued on nph 14u qhs with regular insulin sliding scale with good control of her sugars. #. hyperlipidemia- patient continued home simvastatin 40mg daily fen: mechanical soft; nectar prethickened liquids soft solids. meds whole with nectar or puree. 1:1 supervision. ppx: -dvt ppx with heparin sc tid -ranitidine for gi, senna/colace for bowel -pain management with tylenol access: piv's medications on admission: nph 14 units qhs regular ssi ciprofloxacin 200 mg iv q12h (-) hydromorphone (dilaudid) 1 mg iv q4h:prn pain acetaminophen 1000 mg po/ng q6h vancomycin 1000 mg iv q 12h (-) miconazole 2% cream 1 appl tp lorazepam 0.5 mg po/ng tid lidocaine 5% patch 1 ptch td daily ferrous sulfate 325 mg po/ng daily atenolol 100 mg po daily glucagon 1 mg im q15min:prn hypoglycemia protocol dextrose 50% 12.5 gm iv prn hypoglycemia protocol metronidazole (flagyl) 500 mg iv q8h (-) senna 2 tab po/ng :prn consitpation oxycodone (immediate release) 5-15 mg po/ng q4h:prn pain simvastatin 40 mg po/ng daily ranitidine 150 mg po bid enalapril maleate 20 mg po daily trifluoperazine hcl 2 mg po daily amitriptyline 25 mg po hs discharge medications: 1. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 2. trifluoperazine 2 mg tablet sig: one (1) tablet po daily (daily). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for consitpation. 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 9. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day). 10. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety. 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 13. phenol 1.4 % aerosol, spray sig: one (1) spray mucous membrane q6h (every 6 hours) as needed for sore throat. 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. nph insulin human recomb 100 unit/ml suspension sig: fourteen (14) units subcutaneous at bedtime. 16. insulin- sliding scale continue insulin sliding scale per attached document 17. vancomycin vancomycin 1250mg iv q24hr x 8 weeks 18. flagyl flagyl 500mg iv q8hr for duration of vancomycin treatment plus an additional 5 days 19. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 20. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 21. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: - discharge diagnosis: primary: osteomyelitis, acute kidney injury secondary: diabetes mellitus, hypertension discharge condition: good. vital signs stable. mental status clear and at baseline. discharge instructions: you were admitted to the hospital to undergo back surgery for your spine infection. you tolerated the procedure well and seem to be improving daily. you were found to have low urine output after your procedure. this improved each day and your kidney function seems to be returning to normal. the following changes were made to your medications: 1. please take vancomycin 1250mg iv every 24 hours 2. please start taking lasix 40mg by mouth daily 3. please stop taking your atenolol 4. please start taking metoprolol tartrate 50mg by mouth twice a day 5. please stop taking your enalapril until your kidney function returns to its baseline. your physicians should check your vancomycin level periodically and re-dose the medication as needed. followup instructions: provider: , md phone: date/time: 11:30 provider: , md phone: date/time: 11:30 please follow-up with your cardiologist, dr. , on , at 1:45pm. you can contact him at . procedure: venous catheterization, not elsewhere classified lumbar and lumbosacral fusion of the anterior column, posterior technique other exploration and decompression of spinal canal local excision of lesion or tissue of bone, other bones lumbar and lumbosacral fusion of the anterior column, anterior technique other partial ostectomy, other bones insertion of interbody spinal fusion device fusion or refusion of 2-3 vertebrae fusion or refusion of 2-3 vertebrae insertion of recombinant bone morphogenetic protein diagnoses: other iatrogenic hypotension acute kidney failure with lesion of tubular necrosis unspecified pleural effusion toxic encephalopathy unspecified essential hypertension acute posthemorrhagic anemia diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes depressive disorder, not elsewhere classified other and unspecified hyperlipidemia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site long-term (current) use of insulin intestinal infection due to clostridium difficile intraspinal abscess acute osteomyelitis, other specified sites other and unspecified disc disorder, lumbar region lumbosacral spondylosis without myelopathy diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled background diabetic retinopathy oliguria and anuria infection following other infusion, injection, transfusion, or vaccination psoas muscle abscess degeneration of lumbar or lumbosacral intervertebral disc 

Answer: The patient is high likely exposed to