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: tetracycline / vancomycin attending: chief complaint: pancreatic lesion bleed major surgical or invasive procedure: splenic artery pseudoaneurysm embolization picc line placement x 2 history of present illness: 54 year old woman with history of chronic multiple sclerosis, osteomyelitis, mrsa wounds/esbl urinary tract infections, diverting colectomy w/ colostomy, sacral decub (stage 4), depression, hyperlipidemia who presents with pancreatic hemorrhaging. the patient initially presented to with altered mental status on . she was diagnosed with possible wound infection and started on iv vancomycin, in discussions with infectious disease. there was also some concern for cdifficile infection and so the patient was initially on po vancomycin but all stool cultures this admission were negative. the patient was also briefly on meropenem for unclear reasons. . the patient had reported abdominal pain on admission and ct abdomen revealed pancreatitis although lipase was 47. gi was consulted and egd documented a large duodenal ulcer without bleeding. ct abdomen subsequently showed portal and splenic vein thrombosis. heme/onc was consulted and diagnosed the patient with protein c and s deficiency; these may have been spurious diagnoses in the setting of having already started the patient on coumadin (confounder). thus, heme/onc felt strongly about anticoagulation (dalteparin) although gi at the osh was concerned regarding hemorrhaging into the pancreas given recent pancreatitis. the patient continued to have abdominal pain and had a hemoglobin/hematocrit drop with associated bright red blood in ostomy. hematocrit at its very lowest was 23.6. on repeat ct abdomen yesterday, she was found to have an actively hemorrhaging pancreatic lesion and non-acute pancreatitis. the lesion was 10.5 x 2.2 cm. the surgical team was consulted but had not seen her prior to transfer. the patient had been treated since admission with iron for presumed iron deficiency anemia. the patient was initially to be transferred to medicine floor but acutely dropped her bps to sbp90s at the osh. she was transfused two units of blood (baseline hct 26) with lasix in between, prior to transfer to . . the patient was found to severely malnutritioned, with albumin 1.6. . urology was also consulted for recurrent urinary tract infections, neurogenic bladder and recommended bladder neck closure and suprapubic catheter when more medically stable. . vital signs prior to transfer: t99.3, bp98/68-120/63, hr 80 (sinus), rr13-17, 98% o2 sat on 2l nasal cannula. . on arrival in the micu, vs were t 97.0, bp102/78, hr 82, rr 16, 98% on 2l nasal cannula. the patient was resting uncomfortably in bed. . ros: patient resting comfortably in bed, states she feels very tired. endorses pain in right hip and lower back, otherwise no complaints. breathing feels okay. past medical history: * chronic multiple sclerosis (nursing home bound) * osteomyelitis * stage 4 sacral decubitus ulcer * prior mrsa wound infections * esbl e. coli urinary tract infections * diverting colectomy, colostomy * hyperlipidemia * malnutrition * depression * ?congestive heart failure * ovarian cysts * cervical cancer, ?ovarian cancer * bilateral knee replacements * osteoarthritis social history: lives at wood mill care and rehabilitation center, in , ma. was a bartender several years ago. t - ppd "for a long time" quit in 1/. a - social. d - cocaine quit couple years ago. currently denies illicits. has two sons who live in . . family history: no known family history of coagulopathy, sudden cardiac death, cancers, pancreatitis/gallstones. physical exam: admission exam: vs: temp: 97.8 bp:102/73 hr: 80 rr: 20 o2sat 100% on 2l nc gen: pleasant, comfortable, nad, chronically ill appearing, pale heent: perrl, eomi, anicteric, pale conjunctiva, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: non-tender, non-distended but obese with multiple well-healed surgical incision sites, +bs, colostomy bag w/ pink granulation tissue ext: no cyanosis, ecchymosis, edema skin: no rashes/no jaundice/no splinters; reportedly has left gluteal ulcer near ischial tuberosity (4.5x4.4), deep sacral ulcer 6.3x10x4 with wound vac removed neuro: aaox3. cn ii-xii intact. 3/5 strength throughout. sensation grossly intact. discharge: vs: 98.9, bp: 118/74, p: 85, rr: 20, 98% on room gen: friendly, chronically ill appearing female in nad, hospital cv: rrr, no m/r/g pulm: ctab abd: bs+, soft, nt, nd, ostomy in place in r mid abdomen- filled with gas and stool ext: no edema, good pulses skin: left gluteal ulcer- 4x4 cm covered in eschar- seen under bandage, stage 4 deep sacral ulcer neuro: cn ii-xii intact. 3/5 strength throughout. sensation grossly intact. pertinent results: 09:46pm glucose-80 urea n-14 creat-0.2* sodium-137 potassium-3.4 chloride-100 total co2-29 anion gap-11 09:46pm estgfr-using this 09:46pm alt(sgpt)-75* ast(sgot)-76* ld(ldh)-265* alk phos-405* tot bili-0.7 09:46pm lipase-41 09:46pm albumin-2.3* calcium-8.4 phosphate-3.8 magnesium-2.0 09:46pm triglycer-188* 09:46pm wbc-12.4* rbc-3.54* hgb-10.2* hct-30.4* mcv-86 mch-28.7 mchc-33.5 rdw-18.4* 09:46pm neuts-68 bands-0 lymphs-23 monos-5 eos-4 basos-0 atyps-0 metas-0 myelos-0 09:46pm hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-1+ spherocyt-1+ ovalocyt-1+ target-1+ schistocy-1+ 09:46pm plt smr-normal plt count-387 09:46pm pt-15.5* ptt-32.6 inr(pt)-1.4* . discharge: 06:40am blood wbc-10.6 rbc-3.32* hgb-9.7* hct-29.7* mcv-90 mch-29.1 mchc-32.5 rdw-17.1* plt ct-600* 06:40am blood glucose-107* urean-19 creat-0.3* na-136 k-4.0 cl-103 hco3-23 angap-14 05:33am blood alt-26 ast-21 ld(ldh)-200 alkphos-325* amylase-47 totbili-0.2 06:40am blood calcium-9.8 phos-5.4* mg-2.0 . cxr: left picc terminates in the region of the cavoatrial junction. this finding was discussed with dr. at 2:30 a.m. by telephone by dr. . size is normal. patchy bibasilar opacities are present, which could be due to atelectasis, aspiration, or infectious pneumonia. small right pleural effusion is also noted. . abdominal ultrasound with dopplers: 1. no evidence for recurrent flow within the thrombosed splenic artery pseudoaneurysm. 2. reversal of flow within the splenic vein, the significance of this finding is uncertain. the splenic parenchyma was not evaluated on this examination which was targeted to assessment of the pseudoaneurysm. . cta: 1. no pulmonary embolism or acute aortic pathology. bilateral small pleural effusions and bibasal atelectasis. lue picc ends in the lower svc. 2. thrombosis of the main and right portal vein, likely chronic thrombosis of the left portal vein. enhancement is not appreciated within the narrowed splenic vein, likely thrombosed. patent hepatic veins. minimal perisplenic fluid, but no evidence of splenic infarcts. 3. s/p thrombin injection into the splenic artery pseudoaneurysm, with a 6mm focus of arterial enhancement in the region, suggesting minimal recanalization /residual flow. 4. fat stranding surrounding the pancreatic tail/pseudoaneurysm, with small phlegmon and fluid collection adjacent to the pancreatic tail, s/o pancreatitis. s/p diverting rlq loop colostomy. brief hospital course: 54 year old woman with history of chronic multiple sclerosis, osteomyelitis, diverting colectomy/colostomy, stage 4 sacral decubitus ulcer, prior mrsa wound infections and esbl e.coli urinary tract infections, hypertension, hyperlipidemia who presents with peripancreatic hemorrhage from where she was admitted for altered mental status, pancreatitis, possible wound infection and transferred to on . # peripancreatic hemorrhage: pseudoaneurysm suggested on this patient's ct abdomen between a pseudocyst and the splenic vein. it is possible, given the recent bright red blood in her colostomy (although not currently) that there has been some bleeding into the pancreatic duct as well (hemosuccus pancreaticus). consulted ir for mesenteric angiography with embolization vs. coiling for pseudoaneurysm. on , interventional radiology attempted stenting across the aneurysm but was unable due to toruosity of the splenic vein. instead, using ultrasound guidance, thrombin was injected and the patient's hematocrits remained stable. the patient underwent repeat abdominal ultrasound with dopplers which showed stable pseudoaneurysm after ir intervention. the patient's hematocrit remained stable and did not require any blood transfusions while at . # portal vein and splenic vein thrombosis: complications of pancreatitis due to peri-pancreatic inflammation and can actually cause gastric varices with portal hypertension. if patient's protein c and s levels were drawn while on coumadin, they were likely inaccurate. pt will need weeks off therapy before she can re-evaluated for coagulopathies. anticoagulation was held as an inpatient as she remained asymptomatic and it was discussed with hepatology who recommended no anticoagulation in the near future. pt will need outpt hematologic workup for protein c and s deficiency in the future. # pancreatitis: possibly due to gallstones seen on ct and abdominal ultrasound. patient's lipase was not elevated at the osh but had radiological findings and abdominal pain. the patient's abdominal pain gradually resolved, initially as npo with ivf/tpn and then advanced a regular diet. pt will need ongoing monitoring of nutrition intake given her low albumin. # esbl urinary tract infections: evaluated by urology at osh and felt to have neurogenic bladder and would benefit from suprapubic catheter. urine culture repeated on admission showed vre although urinalysis was bland. the patient catheter was changed and repeat ua showed possible infection. of note, on exam during foley catheter change, the patient's urethra appeared enlarged/stretched. urology was consulted and on evaluation, felt that the patient's urethra had likely been gradually dilated given multiple sclerosis and leaking around catheter. each time she leaked, the patient's catheters were likely upsized, resulting in dilation. the patient will likely benefit from suprapubic catheter placement in the future. patient grew enterococcus on repeat urine culture with a rising leukocytosis. linezolid was not used due to concern for serotonin syndrome. daptomycin allergy was actually "warmth" and so patient carefully monitored and treated with daptomycin which she tolerated without difficulty. patient was started on daptomycin 350 mg iv q24 on and should continue until for a 14 day total course. # stage 4 sacral decubitus ulcer and lateral gluteal ulcer: stable, previously with wound vac. patient has a history of mrsa wound infections. wound care consulted and daily wound care received while in house. she was continued on zinc and vitamin c to help with wound healing. # multiple sclerosis: stable, patient lives at a rehab/nursing facility at baseline. the patient was resumed on her home baclofen and neurontin. # picc line infection: blood culture from left sided picc line grew gpcs in clusters in bottles. decision was made to pull picc line given likelihood of line infection. at the time of discharge, the picc tip cx was negative for growth at 48hrs but pt had been getting daily infusions of daptomycin through this line. a picc line was resited in right antecubital fossa, and chest ap portable film confirmed placement in the mid svc, and is ready to use upon discharge. # diverting colectomy, colostomy: unclear original reason for colostomy possibly to prevent infection of decub. continue to monitor ostomy which was guaiac positive in the micu. serial hematocrits remained stable. patient has known esophageal ulcer on osh egd. she was continued on oral ppi daily. she is scheduled to follow up with gi for egd biopsy results. # hyperlipidemia: stable, held gemfibrozil given pancreatitis. . # malnutrition: albumin significantly low at 1.6 at osh and 2.3 here. nutrition was consulted for for tpn. continue multivitamin, calcium, vitamin d. the patient is at risk for infection on tpn, given past history. nevertheless, she was started on tpn with simultaneous encouragement for po intake. tpn was stopped on . she is not a candidate for g tube placement at this time due to esophageal ulcer but should be re-evaluated in weeks. . # depression: stable, continue wellbutrin sr, zyprexa and lamictal. . # osteoarthritis: s/p bilateral total knee replacements, pt requested vicodin for pain management, which was increased to q4h prn. her morphine liquid solution was stopped. . #code status: dnr/dni daptomycin allergy: the report of daptomycin allergy was not confirmed. patient was monitored carefully while getting daptomycin and did not have any reactions. recommended follow-up: follow-up: -please make sure patient sees a gastroenterologist within 2 weeks after discharge for management of pancreatitis/pancreatic hemorrhage. we have arranged for follow-up for a gastroenenterologist at but feel free to cancel this appointment and make arrangements with a different gastroenterologist. - patient will need mrcp to look for signs of liver malignancy or infiltrative disease. - she should be reevaluated for g-tube placement in weeks. - she should have repeat contrast ct of the abdomen to evaluate for residual pancreatic pseudoaneurysm medications on admission: * baclofen 10mg three times dialy * benadryl 25mg daily prn * calcium-vitamin d 500mg twice daily * multivitamin daily * neurontin 300mg qhs * omeprazole 20mg daily * potassium 20meq daily * simethicone 160mg three times daily prn * natural tears gtt * trazodone 500mg qhs * tums 1000mg three times daily prn * tylenol 1000mg every four hours for pain * valium 5mg three times daily * vicodin 5-500mg twice daily * vitamin c 500mg twice daily * zinc sulfate 220mg daily * colace 100mg twice daily prn * wellbutrin sr 100mg twice daily * zyprexa 5mg qhs * morphine 20mg/5ml 8 mg sublinguially prn pain (q4 hours) * lamictal 100mg qhs * dalteparin 5000 units daily * zofran 4mg every 6 hours prn nausea * zoloft 50mg daily * ketoconazole 2% cream to buttocks daily * esenex 2% powder topical twice daily prn itch * calazime topical lotion daily to red groin areas * selenium sulfide 2.5% lotion to eyebrows, scalp prn seborrhea * immodium 2mg daily prn * lopid 600mg qhs . meds on transfer: asked to fax over discharge medications: 1. baclofen 10 mg tablet sig: one (1) tablet po tid (3 times a day). 2. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po twice a day. 3. multivitamin tablet sig: one (1) tablet po once a day. 4. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. simethicone 80 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day) as needed for gas, abdominal pain. 7. natural tears (pf) 0.1-0.3 % dropperette sig: one (1) drop to both eyes ophthalmic once a day. 8. trazodone 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 9. tums 200 mg calcium (500 mg) tablet, chewable sig: two (2) tablet, chewable po three times a day as needed for heartburn. 10. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: do not exceed 4 gm acetaminophen in 24 hours . 11. vitamin c 500 mg tablet sig: one (1) tablet po twice a day. 12. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 13. daptomycin 500 mg recon soln sig: 350 mg intravenous every twenty-four(24) hours for 4 days: until . 14. senna 8.6 mg capsule sig: one (1) tablet po bid (2 times a day) as needed for constipation. 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 16. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). 17. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)). 18. bupropion hcl 100 mg tablet extended release sig: one (1) tablet extended release po bid (2 times a day). 19. lamotrigine 100 mg tablet sig: one (1) tablet po at bedtime. 20. insulin lispro 100 unit/ml solution sig: one (1) injection subcutaneous asdir (as directed): see sliding scale . 21. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 22. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 23. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every six (6) hours as needed for nausea. 24. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 25. ketoconazole 2 % cream sig: one (1) appl topical daily (daily). 26. esenex sig: one (1) application twice a day as needed for itching: 2% topical powder. 27. calamine lotion sig: one (1) application topical once a day as needed for itching: to red groin areas. 28. selenium sulfide 2.5 % suspension sig: one (1) application topical once a day as needed for seborrhea: to eyebrows, scalp. 29. imodium a-d 2 mg tablet sig: one (1) tablet po once a day as needed for diarrhea, excessive stools . discharge disposition: extended care facility: colonial heights care and rehabilitation center - discharge diagnosis: primary diagnosis: pancreatitis splenic artery pseudoaneurysm hemorrhage portal and splenic vein thrombosis urinary tract infection malnutrition . secondary diagnoses: multiple sclerosis stage 4 sacral decubitus ulcer hypertension hyperlipidemia colostomy discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: dear ms. , you were transferred to the because you were having a large bleed from your pancreas. we had to perform a procedure to stop the bleeding. you also developed blood clots in some of the veins in your abdomen. you developed an urinary tract infection and we gave you medications to treat that. you had very poor nutritional status and so we gave you nutrition through your veins. . the following changes were made to your medications: added: - started daptomycin 350 mg iv every 24 hours until for 14 day course - started pantoprazole 40 mg by mouth daily - remeron (mirtazapine) 7.5 mg by mouth at night changed: - increased frequency of vicodin from twice a day to every 6 hours as needed for pain removed: - stopped omeprazole (added pantprazole instead) - stopped morphine liquid suspension (increased frequency of vicodin) - stopped gemfibrozil - stopped valium - stopped benadryl followup instructions: please make an appointment and follow-up with your primary care doctor within 3 days after discharge. . department: div. of gastroenterology when: wednesday at 1 pm with: , md building: ra (/ complex) campus: east best parking: main garage procedure: parenteral infusion of concentrated nutritional substances injection or infusion of other therapeutic or prophylactic substance arteriography of other intra-abdominal arteries diagnoses: urinary tract infection, site not specified depressive disorder, not elsewhere classified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pressure ulcer, buttock pressure ulcer, lower back pain in joint, pelvic region and thigh primary hypercoagulable state streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] do not resuscitate status multiple sclerosis other and unspecified infection due to central venous catheter knee joint replacement acute pancreatitis cyst and pseudocyst of pancreas other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria pressure ulcer, stage iv ulcer of esophagus without bleeding nutritional marasmus other diseases of spleen portal vein thrombosis attention to colostomy personal history of methicillin resistant staphylococcus aureus neurogenic bladder nos aneurysm of other visceral artery 

Answer: The patient is high likely exposed to