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: patient recorded as having no known allergies to drugs attending: chief complaint: leg pain, fever major surgical or invasive procedure: transesophageal echo urgent aortic valve replacement with size 23 st. epic tissue valve history of present illness: is 46 yo f with hx of ivdu, hcv, granulomatous disease of gi tract, liver, spleen, and bone, hx of cellulitis, osteomyelitis of spine, and chronic leg ulcers, and anxiety who p/w 2 days of leg pain, right worse than left, bilateral leg swelling that feel hot to touch. she was in her usual state of health until 2 days ago when she noticed that her r leg was painful and swollen, she took 6 advil for pain relief which did not help. measured her fever at home to be 103. yesterday, she began to notice swelling and pain in her l leg. no recent trauma in the area, no open cuts or wounds preceding swelling. she was seen yesterday at osh where she was advised to be admitted for antibiotics, she left ama because she had a negative experience during an admission last year. did not get any antibiotics po on discharge. last night, she used a pin to put a hole in her r leg in hopes of relieving pressure, noticed minimal clear drainage from the area. of note, pt has chronic venous stasis changes with erythema on r leg. also has large ulcers in inguinal areas l>r (6cm ulcer with pus and drainage in l inguinal area, 1cm ulcer in r), she does dressing changes for these daily at home using silvedene. inguinal ulcers are heroin injection, pt reports she has not injected in about 6 months and ulcers have improved since then. she never injected in her toes, has not injected in arms in many years due to scarring. pt says she was tested for hiv since stopping drugs and has been negative, hcv infection is "inactive" per her, she was never treated for this. . in ed vitals were 99.2, 96/49, 78, 16, 97% ra, she received 1g vancomycin. . review of systems: + weight loss of 15 lbs in past month, decreased appetite; chronic headaches; + non-productive cough of few days no n/v, no diarrhea, no changes in urine or bowel, abdominal distension at baseline per pt past medical history: hepatitis c antibody positive, negative vl , neg vl hiv negative as of ivdu with unclear timeline of use deficiency anemia septic r shoulder s/p drainage and debridement of rotator cuff osteo of spine thigh ulcers (left upper thigh ulcer for >7 years) mssa bacteremia with endocarditis resulting in 8 week admission in mssa osteo resulting in 7 week admission in non-caseating granulomas (): liver biopsy, bone marrow, gastric antrum thought to be the etiology of her elevated alk phos (likely a result of injecting heroin with cocaine containing talc) social history: lives with parents given need for assistance but has her own home. parents are incredibly supportive and caring. patient also has a sister, brother and step-brother who are involved in her life. she no longer works. hx of ivdu, cocaine, heroin but clean for 6 months. >60 pack year history now 6 cigs/day, hx of etoh abuse now quit 10 years ago. had daughter who died 2 years ago at age 24 from overdose. family history: denies famiy history of ca, htn, heart disease, liver disease. physical exam: ga: aox3, nad heent: perrla, moist oral mucosa, anicteric sclera cards: rrr, s1/s2, holosystolic murmur in lusb pulm: coarse breath sounds b/l, no wheezes or rales abd: soft, distended, + hepatosplenomegaly, no appreciable fluid wave, non-tender, no rebound/guarding 6x6cm draining ulcer in l inguinal area; 1x1cm ulcer in r inguinal area extremities: r>l edema and erythema, no distinct border, warm to touch b/l, erythematous, small draining tract on r dorsal shin, scaling b/l, 2+ distal pulses neuro/psych: cns ii-xii intact. no motor deficits, gait not assessed pertinent results: admission labs: . 12:35pm blood wbc-6.4# rbc-2.94* hgb-9.2* hct-27.4* mcv-93 mch-31.4 mchc-33.7 rdw-14.7 plt ct-217 12:35pm blood neuts-81.4* lymphs-13.3* monos-3.0 eos-2.1 baso-0.3 12:35pm blood glucose-94 urean-33* creat-1.9* na-134 k-5.5* cl-101 hco3-22 angap-17 07:30am blood alt-24 ast-25 alkphos-276* totbili-0.4 07:30am blood calcium-8.3* phos-3.1 mg-1.9 07:15am blood caltibc-147* hapto-189 ferritn-761* trf-113* 07:00am blood vitb12-419 folate-12.2 07:30am blood afp-1.2 . 05:54am blood wbc-4.9 rbc-2.67* hgb-8.4* hct-24.7* mcv-93 mch-31.5 mchc-34.1 rdw-17.3* plt ct-215 03:38am blood wbc-5.1 rbc-2.67* hgb-8.5* hct-24.7* mcv-93 mch-31.6 mchc-34.2 rdw-17.4* plt ct-217 05:54am blood glucose-96 urean-18 creat-1.0 na-139 k-3.2* cl-101 hco3-31 angap-10 03:38am blood glucose-93 urean-21* creat-1.3* na-137 k-3.0* cl-98 hco3-31 angap-11 03:17am blood glucose-114* urean-17 creat-1.3* na-139 k-3.8 cl-102 hco3-27 angap-14 tee pre-bypass: the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. no atrial septal defect is seen by 2d or color doppler. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is moderately depressed (lvef= 30-35 %). the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. there is a mass in the right ventricle. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to xx cm from the incisors. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. posr cpb: 1. improved -ventricular systolci function with inotropic support 2. bioprosthetic valve in aortic p heroin use b/l and fever, found to have mssa bacteremia and aortic valve endocarditis. . # mssa bacteremia - blood cultures () bottles from admission positive for mssa. the most likely source is the bilateral chronic non-healing ulcers heroin use. though pt reports not having used heroin in the past 6 months, ulcers have not healed despite dressing changes at home. on admission, ulcers appeared infected and pt was febrile. pt was started on iv nafcillin for mssa, to complete a total 6-week course. of note, pt has history of mssa infections in the past (abscesses, bacteremia, and r sided endocarditis) for which she completed nafcillin courses. pt also had history of thoracic osteomyelitis in treated at , though this was considered as possible source of bacteremia on this admission, it seems less likely given no clinical symptoms of back pain and more likely source of ulcers. pt refused mri imaging, but should consider outpatient open mri if does not continue to have improvement. all surveillance cultures since admission have had no growth to date. as described below, pt was found to have aortic valve vegetation and infective endocarditis with no abscess seen on tee. . # endocarditis - in setting of mssa bacteremia, pt was found to have 1.4cm vegetation on aortic valve, new since echo in , with moderate aortic insufficiency. started on 6-week course of iv nafcillin as above. cardiology and ct surgery were consulted and did not recommend acute surgical intervention given bacteremia and no decompensated heart function. daily ecgs did not show any abnormalities, pt had hypotension to sbp 100 throughout most of hospital stay and one episode of fever to 100.5 a week into therapy; given this, a tee was done to evaluate for cardiac abscess and was negative for this. -patient was transferred into micu after code was called on floors for hypoxic respiratory failure. this respiratory failure was quickly reversed with diuresis and nimv, and was thought to be severe aortic valve insufficiency in the setting of patient anxiety. similar episodes occurred intermittently in the icu with any mild increase in svr, so patient was kept with sedative/opiate regimen to stave off anxiety. cardiac surgery was consulted, and it was agreed that surgical correction of valve was only viable therapeutic option. . # inguinal ulcers - long-standing heroin use though pt reports no use for past 6 months. she had been doing daily dressing changes at home though these ulcers were likely infected on admission (6x6cm in l anterior thigh area, 2x2cm in r). wound care and plastic surgery were consulted, plastic surgery did not recommend surgical debriding, pt had wet-to-dry dressing changes three times a day which required 1mg iv dilaudid for pain control beforehand. once pt completes antibiotic course for bacteremia and endocarditis, she will follow up with plastic surgery to consider flap placement to ensure healing. pt had bilateral venous stasis changes and 1+ edema below knees, in addition to leg elevation and betamethasone cream, she was diuresed with lasix and had decrease in edema and pain in legs. . # acute renal insufficiency - likely pre-renal given poor po intake recently and infection. cr improved to 1.3 today, fena 2.5% and feurea 52% both of which suggest resolution of pre-renal state - encourage po intake - continue to trend cr . # hypotension - now improved, sbp 110s-120s. given aortic valve vegetation, will maintain high suspicion for valve dysfunction contributing to hypotension. - encourage po intake - monitor on tele, daily ecgs - continue abx as above . # anemia - chronic, hct baseline 26-27, studies in revealed likely etiology as anemia of chronic inflammation. panel indicates likely aci, no evidence for hemolysis. hct bumped appropriately to 1u rbc. hct stable today. - t+s, piv - peripheral smear - no schistocytes - b12 / folate - normal . # anxiety - continue home 1mg tid ativan . # hcv - "inactive", never treated for this. pt had liver biopsy in which showed fibrosis with no clear etiology for hepatomegaly. she follows in clinic here. recent poor appetite and weight loss is concerning for malignancy, though afp not elevated. - outpt work-up for ?malignancy - lfts stable # ivdu - pt reports being clean for 6 months - social work consult micu course the patient is a 46 yo f with hx of ivdu complicated by mssa verebral osteo , and prior history of endocarditis at , h/o mrsa/pseudomonal hip wound infection, hcv, granulomatous disease of gi tract, chronic inguinal ulcers, and anxiety with mssa endocarditis who was transferred to the micu for hypercarpic respiratory failure and code blue after being briefly unresponsive. . #. hypercarpic respiratory failure: pt initial abg showed ph 6.84 and pco2 of 112. the differential for her respiratory failure was medication related especially opioid use causing respiratory depression. although pt with high tolerance and has been stable on dilaudid dosing and no recent increase. the patient does have a history of drug abuse and could have had an alternate source of drugs or been hording her medications. pt also could have fallen because of a seizure with head injury leading to bleed or embolic/hemorrhagic stroke given endocarditis, but pt awake and interactive making major cns process unlikely. pt does not have a history of copd or other history of bronchospasm. cxr did not show clear evidence of acute pathology. lenis performed yesterday negative for dvt, making pe less likely. pt was extubated after being intubated for 2 days and sating well on 2l nc/ra. . #. mssa endocarditis: pt previously on nafcillin for mssa endocarditis seen on tee. pt had stat echo performed at bedside by cardiology id consulted and recommended changing to vancomycin and meropenem given concern for sepsis upon initial presentation to icu, which was later switched back to nafcillin given stable bp's and clinical status, as this provides better coverage of her mssa bacteremia.follow-up blood, urine and sputum cultures . # hypotension: likely cardiogenic shock given markedly decreased ef. sepsis was initially also a concern in this pt with mssa endocarditis but given mixed venous of < 70, cardiogenic is more likely. required briefly phenylephrine but was later weaned off and tolerated well without. tte repeated yesterday showed ef 40%, worsening ar. was transfused 2 units of prbc's. . #. ecg changes: pt with inverted t-waves in the setting of her severe acidosis and tachycardia. troponin peaked at 0.27 and trended down at 0.22. per cardiology, will not pursue anticoagulation for concern of acs , according to echo report patient most likely experienced coronary artery embolization from her endocarditis . #. s/p fall: pt found down for undetermined time. she is currently complaining of neck pain. mri of the cervial and thoracic spine was unremarkable and trauma surgery cleared the patient. . # inguinal ulcers - long-standing heroin use. no evidence of infection and was being followed by plastics. - wound care with wet to dry dressings tid . # hcv - never underwent treatment. pt had liver biopsy in which showed fibrosis with no clear etiology for hepatomegaly. trended lfts q daily . # ivdu - pt reports being clean for 6-8 months per prior notes .social work following . #??????cr elevated to 1.6 from low of 1.1 a few days ago. be hypoperfusion cardiogenic shock. ua also positive; may have thrown septic emboli to kidneys. urine lytes showed a boderline prerenal etiology with fe urea 28%. eosinophil smear showed..... . # chronic pain??????on opioids for pain. however, given respiratory failure after receiving dilaudid and ativan, will be conservative in dosing, ordered lorazepam 1 mg po/ng q6h:prn anxiety , hydromorphone (dilaudid) 0.5-1 mg iv q3h:prn pain/agitation . #anemia: hct drop from 27 to 22 this morning, 20 on repeat. transfused 2 units prbcs,did not increase appropiately to first unit and dic labs were sent which were unremarkable, guiac stools... cardiac surgery course: the patient was brought to the operating room on where the patient underwent aortic valve replacement with 23mm porcine tissue valve. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. the patient remained intubated on pod 1 as she had no cuff leak and had been intubated multiple times during this admission, and it was decided to manage her conservatively. she remained on epinephrine and propofol drips. decadron was initiated for lack of cuff leak on pod 2. pod 3 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. acute pain service was consulted, as she has a h/o ivda and refused ms contin or oxycontin. recommendations were made for dilaudid. id continued to follow and the patient is to be maintained on nafcillin for a 6 week course through . picc was placed to facilitate therapy. fluconazole was initiated for yeast in the urine. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to , in good condition with appropriate follow up instructions. medications on admission: currently taking only 1 mg lorazepam three times a day for anxiety. does not take any other medications at present. medications were reviewed and reconciled with the patient. discharge medications: 1. betamethasone valerate 0.1 % ointment sig: one (1) appl topical (2 times a day): apply to both legs twice a day. 2. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 3. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 4. lorazepam 1 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. hydromorphone 2 mg tablet sig: 3-5 tablets po q3h (every 3 hours) as needed for pain. 8. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 12. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 13. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 14. nafcillin 2 g iv q4h 15. nafcillin 2 gram recon soln sig: one (1) intravenous every four (4) hours for 2 weeks: last day of treatment . 16. hydromorphone (dilaudid) 1 mg iv bid:prn dressing changes 17. furosemide 40 mg tablet sig: one (1) tablet po once a day for 2 weeks. 18. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 2 weeks. discharge disposition: extended care facility: - discharge diagnosis: mssa bacteremia infective endocarditis, s/p avr pmh: ivda -heroin(says clean 6months). ulcers/cellulitis b thighs. hepc, ascites,t9 osteo w/paraspinal abscess ,hepatosplenomegaly discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage edema- 1+ les discharge instructions: medical service: it was a pleasure taking care of you at . you were admitted with fevers and leg pain. we found a bacteria growing in your blood called mssa (which you have had in the past) and we started you on appropriate antibiotics for this. we did an echocardiogram of your heart which showed that the bacteria had spread to a valve in your heart. your heart function was monitored and was stable throughout your hospital stay. the most likely source for your infection are the ulcers on your legs. our plastic surgery team recommended that you get these debrided during dressing changes by using wet-to-dry dressings, which we have been doing three times a day in the hospital. we gave you some water pills to take the fluid out of your legs. you should continue your antibiotic course for a total of 6 weeks . we have made the following changes to your medications: continue nafcillin for 6 weeks total (last day = ) cardiac surgery: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: the following appointments have already been scheduled for you: . department: div of plastic surgery when: friday at 2:00 pm with: , md building: lm bldg () campus: west best parking: garage . department: when: monday at 11:40 am with: , building: sc clinical ctr campus: east best parking: garage . department: infectious disease when: thursday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage cardiac surgery provider: , md phone: date/time: 1:30 cardiology: dr on at 11:40am md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours extracorporeal circulation auxiliary to open heart surgery combined right and left heart cardiac catheterization coronary arteriography using two catheters diagnostic ultrasound of heart insertion of endotracheal tube non-invasive mechanical ventilation open and other replacement of aortic valve with tissue graft cardiopulmonary resuscitation, not otherwise specified diagnoses: anemia of other chronic disease congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma acute kidney failure, unspecified candidiasis of other urogenital sites aortic valve disorders other chronic pulmonary heart diseases unspecified fall constipation, unspecified anxiety state, unspecified acute respiratory failure cardiac arrest bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site cardiogenic shock acute and subacute bacterial endocarditis unspecified accident diarrhea hematuria, unspecified venous (peripheral) insufficiency, unspecified chronic pain syndrome ulcer of thigh cervicalgia opioid type dependence, in remission acute coronary occlusion without myocardial infarction 

Answer: The patient is high likely exposed to