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 / topamax / codeine / compazine / aspirin / nsaids / toradol / reglan attending: chief complaint: admitted for migraine, fever, back pain, and left sided chest pain major surgical or invasive procedure: picc placement x 2 tee history of present illness: the patient is a 34yo woman with history of complicated migraines, disease, dm, hypercholesterolemia, asthma, and stroke in who came to the ed on for evaluation of headache, and left sided chest pain. she was a questionable historian and much of the following history was obtained from prior records. . during late she experienced heat exhaustion and was admitted to hospital in . at discharge she developed pain, erythema, and swelling on the dorsum of her right wrist (the site of her iv). she was prescribed po keflex as an outpatient. her symptoms persisted and she was admitted to hospital on for thrombophelbitis/cellulitis. she complained of nausea, vomiting, and abdomimal pain. she experienced no fevers, chills, headache, sob, or cough. she was started on iv vancomycin and iv clindamycin. her symptoms improved though did not completely resolve. she was switched to po augmentin (7 day course 875 po bid) and discharged on . during her hospitalization she was also found to be anemic, with no evidence of a "gross bleed." her anemia work-up was deferred to her pcp. . she went back to the hospital at the beginning of because her wrist symptoms had not completely resolved. she was given iv vancomycin and prescribed linezolid. she 't afford the medication and was switched to an unknown dose/course of levaquin. . despite numerous antibiotics, she notes the persistence of mild erythema, pain, and swelling of her left wrist. she lives in ct, and denies any recent outdoor hikes, camping, or tick bites. she came to to visit her sister whose husband was recently injured in . on saturday she experienced an aura of flashing lights and developed an intense migraine. she tried taking an extra dose of neurontin but it didn't help. she was able to sleep,but notes ongoing nausea, vomiting, and photophobia. the migraine pain has been localized mainly on the right side, throbbing, and currently feels as if her eye is "going to out." according to the neurology note she developed r-arm heaviness a few hours after the onset of her headache. ms. 't comment when asked about this. her symptoms persisted and on monday she developed left upper chest and upper back pain. she 't describe the pain further. she denied any sensory changes, motor changes, numbness or tingling. she has no neck pain, facial droop, or slurred speech. . she came to the ed on tuesday () after her sympoms didn't improve. she has had minor migraine relief with dilaudid and phenergan. during her time in the ed, she noted ongoing constant left sided chest pain, which is not affected by breathing. at 6:00 am on she developed fever (103), tachycardia (141), and shaking chills. an ekg was done and showed no st changes and one set of cardiac enzymes was negative. she was given 1 gram iv vanco, had an lp that was unimpressive. a picc was placed due to difficulty establishing access. she was given 2 liters of ns and was transferred to medicine. . upon arrival to the floor, she was tachycardic (108), afebrile, and 96% on room air. she was lying in the dark, looking mildly uncomfortable in bed. she was a poor historian and somnolent througout the interview. she required frequent reminders to stay on subject and often responded inappropriately to questions. her major complaints were right sided migraine and left upper chest and back pain. she also states that her left wrist continues to be mildly painful. shortly after the interview, she developed shaking chills, tachycardia (130), and fever to 103. blood cx and abg were drawn, tylenol was given, and ice was applied. she was given on 1 l normal saline. . ros: she denies weight loss, infectious contacts, ivdu, recent tampon use,no tick bites (though she lives in ct and has a dog), trauma, heavy lifting, sob, doe, pnd, chest pressure, hemoptysis, jaundice, abdominal pain, bowel-bladder changes, vaginal pain/problems, dysuria, hematuria, or bright red blood per rectum. past medical history: - migraine: these began in her late teens and she usually gets at least once a month. she often has auras of flashing lights. her associated symptoms include n/v, photo-and phonophobia. prior to this migraine, her longest migraine lasted 2-3 days. - disease: diagnosed at age 17 during tonsillectomy pre-op workup. multiple bleeding complications through life (bloody noses, heavy periods bleeding from gums, bleeding post-op). she has 3 children, delivered vaginally, and had significant bleeding during and following the deliveries. she ultimately had a hysterectomy due to heavy menstrual bleeding. asa is contra-indicated. she has been treated in the past with whole blood transfusions, ddavp and humate (factor viii). - stroke: , had r-facial droop and was not talking properly-resolved over time. had a headache prior to her symptoms. - ards in , required intubation. woke up on and 't breathe. she was told she had respiratory failure, ards, pneumonia, ecoli sepsis. - asthma-developed after her ards in and has been poorly controlled and required numerous hospital visits. - htn-diagnosed via routine blood work - dm type 2: diagnosed via routine blood work 3-4 years ago. controlled with glucophage. she has no associated eye, kidney, or sensory problems. she doesn't get -asthma-developed after her ards in and has been poorly controlled and required numerous hospital visits. - hypercholesterolemia-diagnosed via routine blood work - obesity . surgeries: - tonsillectomy age 17 significant for early and delayed bleeding. - one ovary removed in with bleeding complications - cholecystectomy and hysterectomy in with late bleeding - back surgergy (l5,s1--herniated discs) and , bleeding complications social history: on admission, her social history was as follows: lives in ct with her fiance , 3 daughters (, , and ), and their (indoor) dog copper. she works as an alcohol/drug counselor. she divorced the father of her 3 children after experiencing several years of physical abuse (she left her husband in and the divorce was finalized two weeks ago). her eldest brother was an addict, and he abused her as a child. she currently feels safe and secure in her home environment and states that her fiance is a "good man." she is not sexually active. . habits: cigaretts: none ethanol: none drugs: none . exposures: she is not aware of any toxin exposure. . trips: she visit over the summer and went on a fishing trip. she lives in ct. she is not aware of any tick, mosquito, spider bites. . health maintanence: she has not received regular medical care. she has seen a physician for her . . she has no pcp. saw an ob/gyn dr. in for her deliveries and hysterectomy. she recieved her primary care from a staff of rotating doctors at the hospital for the past several years, but due to the recent finalization of her divorce, she has lost her benefits. she plans to start care at the women's medical center near her home, if they accept her insurance. family history: dm, htn, cad, migraines, cancer(unsure of types), no other hx of bleeding two grandparents had strokes. her mother and father are in their 60's and have both had mi's. her mother and sister both have migraines. she has 3 brothers and 't comment on their health. she has 3 daughters and had one miscarriage. physical exam: vitals: t 100.1 hr 108 bp 118/70 rr 18 o2sat96%ra fsbs not recorded gen: obese, lying in bed head: nc/at, eyes: perrla, sluggish extraocular movements, patient would not open right eye, no scleral icterus, no conjunctival injections ears: canals not visualized nose: septum midline, no exudate, epistaxis mouth: mmm, symmetrical palatal elevation neck: no carotid bruits;no jvd appreciated due to thick neck, neck supple, able to touch chin to chest nodes: no occipital, pre-auricular, cervical, submandibular, axillary, epitrochlear, or inguinal adenopathy lungs: clear to auscultation bilaterally, breathing rapidly. pressure applied to anterior left chest was mildly tender. pressure applied to upper left paravertebral region was not tender to palpation. heart: heart sounds muffled by increased breath sounds. regular rate and rhythm, normal s1 and s2, no murmurs, gallops and rubs. abdomen: obese, bowel sounds present, soft, nontender, nondistended, no rebound tenderness. large midline scar and central ecchmoses. extremities: erythema l-hand (still swollen, erythematous and warm-no cords detected, tender to palpation), no clubbing, cyanosis, no splinter hemorrhages, spots, lesions. raising either leg elicited extreme pain (localizing to her left upper back) and nausea. . neuro exam deferred by patient. pertinent results: 09:46pm type-art po2-110* pco2-35 ph-7.45 total co2-25 base xs-0 intubated-not intuba 09:46pm lactate-2.3* 05:59pm glucose-93 urea n-8 creat-0.9 sodium-137 potassium-3.6 chloride-102 total co2-25 anion gap-14 05:59pm calcium-9.0 phosphate-2.8# magnesium-2.1 05:59pm wbc-7.7 rbc-3.44* hgb-9.7* hct-27.4* mcv-80* mch-28.3 mchc-35.5* rdw-17.8* 05:59pm neuts-81.7* lymphs-13.6* monos-3.7 eos-0.8 basos-0.1 05:59pm anisocyt-1+ microcyt-2+ 05:59pm plt count-283 05:59pm pt-14.8* ptt-38.6* inr(pt)-1.3* 03:30pm cerebrospinal fluid (csf) protein-34 glucose-68 03:30pm cerebrospinal fluid (csf) wbc-2 rbc-1* polys-8 lymphs-80 monos-12 10:45pm pt-12.6 ptt-34.9 inr(pt)-1.1 10:45pm d-dimer-1258* 10:44pm comments-green top 10:44pm lactate-2.9* 09:39pm glucose-118* urea n-13 creat-1.1 sodium-137 potassium-4.6 chloride-100 total co2-22 anion gap-20 09:39pm alt(sgpt)-22 ast(sgot)-32 ck(cpk)-59 alk phos-88 amylase-30 tot bili-0.4 09:39pm ck-mb-notdone ctropnt-<0.01 09:39pm calcium-9.7 phosphate-4.8* magnesium-2.4 09:39pm hcg-<5 09:39pm asa-neg ethanol-neg acetmnphn-6.3 bnzodzpn-neg barbitrt-neg tricyclic-neg 09:39pm wbc-10.1 rbc-4.01* hgb-11.1* hct-31.8* mcv-79* mch-27.7 mchc-34.9 rdw-17.6* 09:39pm neuts-67.8 lymphs-25.3 monos-4.8 eos-1.9 basos-0.1 09:39pm anisocyt-1+ microcyt-2+ 09:39pm plt count-425 . cxr : no acute pulmonary process. . ecg : sinus tachycardia. no previous tracing available for comparison. . ct /cta : normal, no hemorrhage; cannot see an old stroke or lacune, no pulmonary embolism. . mri/mra : normal circle of . no acute intracranial abnormality. . ecg : probable sinus tachycardia with poor baseline. no change compared to the previous tracing of . . cxr : interval placement of picc line with position as above. . cxr : impression: linear opacity in the right lower lung zone could represent atelectasis. however, early pneumonia cannot be excluded. . cxr : no convincing radiographic evidence of acute cardiopulmonary disease. . echo : the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef 60-70%). the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. the absence of a vegetation by 2d echocardiography does not exclude endocarditis if clinically suggested. . rue u/s : 1) no deep venous thrombosis. 2) occlusive thrombus in the distal, superficial cephalic vein in the right lateral wrist. . panorex : teeth panorex view: multiple missing teeth. dental caries is seen in multiple teeth. there is no obvious abscess visualized. a lucency along the lateral lower incisors does not appear to represent an abscess. no fractures are visualized. the teeth have well defined sclerotic borders. . wrist, 3 views : a true ap view of the wrist was not obtained. no fracture is identified. the joint spaces are preserved. there is prominence of the soft tissues, without a radiopaque foreign body visualized. . tee : the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic, mitral, tricuspid or pulmonic valves. no aortic valve abscess is seen. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. impression: no valvular endocarditis or aortic root abscess identified. preserved biventricular systolic function. . ct abd/pelvis : impression: no intra-abdominal fluid collections or source of infection is identified. brief hospital course: ms. is a 34yf with history of complicated migraines, disease, dm, hypercholesterolemia, asthma, and ?stroke in who came to the ed on for evaluation of headache and left sided chest pain and developed fevers and positive blood cultures, the most likely etiology of which is contamination of picc with oral flora. her hospital course, by problem: . #) fever/tachycardia: she was admitted with fever and back pain, which prompted a lumbar puncture (results were negative). these fevers initially resolved during the first few days of her hospital course, and restarted overnight on . on she also developed a new leukocytosis and was started on vancomycin on for this to cover for possible skin infection (cellulitis) causing fever. she had a ck that remained elevated, and that we attributed to her rigors on admission. an abg on displayed a slight respiratory alkalosis consistent with hyperventilation. she was given scheduled tylenol for her persistent fevers. throughout the admission, blood cultures grew strep viridans, micrococcus, stomatococcus, veillonella, albicans, and lactobacillus. hiv negative. tte/tee have been negative for endocarditis, ophthalmology exam negative for endophthalmitis, no evidence of dental pathology on dental exam and panorex, no evidence of foreign bodies. ct abd/pelvis unrevealing. etiology of positive blood cultures with these organisms points to contamination of picc with oral flora. the picc was pulled out on . patient has been afebrile x 72+ hours. she was put on vancomycin and zosyn iv and oral fluconazole and transitioned to oral antibiotics (augmentin 875mg po tid, clindamycin 450mg po qid, fluconazole 400mg po daily) for discharge; total course to be 14 days (last day of antibiotics ). at the time of discharge, she had been afebrile for >96 hours. from an infectious disease perspective, she is stable for discharge to psychiatric inpatient unit. . #) respiratory distress. patient's o2 saturation decreased to 76% on room air during episode of rigors with fevers on . abg showed hypoxemia. cxr unrevealing. she required overnight observation in the medical icu, during which her oxygen saturations were stable on 2l nasal cannula. after one night, she was transferred back to the floor (), and she continued to sat well on room air without event. . #) psych. patient's belongings were searched on due to suspicion of illicit drug use and injecting into the picc. several syringes and syringe adapters were confiscated, as were a dilaudid prescription bottle and neurontin tablets. tox screen was positive for opiates (known; patient getting dilaudid). phone conversation with patient's mother elucidated substantial psych and substance abuse history. high suspicion that patient has been tampering with picc. the patient had a 1:1 sitter 24 hours per day, including in the bathroom and shower. it was determined that the patient could not leave the hospital without first being seen by psychiatry. . #) atypical chest pain. resolved with hospitalization. a pe was ruled out in the ed via negative cta, nothing focal was noted on the scan. unlikely mi/ischemia as no anginal symptoms (though she is female and a diabetic so symptoms may be atypical). she had two negative sets of enzymes. . #) migraines: her admission migraine headache was consistent with prior migraines however lasting longer than usual. an mri of the head showed no evidence of previous stroke. it has been mildly responsive to phenergen and dilaudid. had c/o right eye pain, no pathology detected on mri/mra, cont to have difficulty opening eye. (her vwd hemotologist) hasn't seen her since and could provide no further information about her stroke or migraines. she was continued on po phenergan, dilaudid 4mg q4h prn, and standing tylenol. in addition, her neurontin was continued. . #) left wrist pain: cellulitis/thrombophlebitis. improved with warm compresses and antibiotics (vancomycin). no evidence of foreign body in left wrist per x-ray. . #) right hand/finger pain: cellulitis due to recent iv access. no streaking up arm. thrombophlebitis on rue ultrasound. improved with warm compresses and antibiotics (vancomycin). . #) lower back pain. patient complained of exquisite pain on palpation of lp site, resolved with rest and pain medications as noted above. . #) anemia. her anemia has been previously documented with unknown cause. her hct has dropped from 31.8 at admission but stabilized around 26. possibly dilutional component, occult losses due to vwd, and iron deficiency. her stools were guaiac negative in the hospital. she should have her anemia worked up as an outpatient. . #) vwd, followed by dr. (hematologist). it is unclear why her inr and pt are elevated, as they should not be affected by pure vwd. she may be vit k deficient or has a mixed coagulopathy that involves the vitamin k factors as well. no active issues during this inpatient stay. . #) diabetes. during this hospitalization, she had 8 straight days of normal blood sugars. her finger sticks and sliding scale were discontinued. she should continue on her home dose of metformin. . #) htn. will continue to monitor blood pressure. atenolol and hctz were continued. . #) asthma: advair and combivent were continued. medications on admission: atenolol 50mg po hctz 25mg po bid glucophage 500mg po daily zocor 40mg po daily advair 50/500 combivent neurontin 900mg po 4 times daily (for migraine proph) ativan 1mg po qhs prn discharge medications: 1. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 2. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po bid (2 times a day). 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 300 mg capsule sig: three (3) capsule po qid (4 times a day). 5. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 6. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain/fever. 7. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. 9. metformin 500 mg tablet sig: one (1) tablet po daily (daily). 10. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. disp:*60 capsule(s)* refills:*2* 12. promethazine 25 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*12 tablet(s)* refills:*0* 13. hydromorphone 2 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*15 tablet(s)* refills:*0* 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 15. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 11 days. 16. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 17. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 11 days. 18. clindamycin hcl 150 mg capsule sig: three (3) capsule po q6h (every 6 hours) for 11 days. 19. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 20. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. discharge disposition: extended care facility: 4 discharge diagnosis: bacteremia, fungemia munchausen's syndrome thrombophlebitis cellulitis migraine headache hypertension hyperlipidemia diabetes asthma discharge condition: stable from a medical perspective. afebrile with stable vital signs. discharge instructions: please take your medications as prescribed, especially your antibiotics. if you experience worsening pain, headache, fevers, nausea, vomiting, or other concerning symptoms, please seek medical attention immediately. followup instructions: please follow up with your primary care provider within one week after discharge from the hospital. please follow up with your hematologist dr. in the next few weeks. it is important that you select a pcp as soon as possible so that you can be followed for your ongoing health issues (diabetes, anemia, high blood pressure, and high cholesterol). md, procedure: venous catheterization, not elsewhere classified spinal tap incision of lung diagnostic ultrasound of heart diagnoses: anemia, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled asthma, unspecified type, unspecified streptococcal septicemia migraine, unspecified, without mention of intractable migraine without mention of status migrainosus phlebitis and thrombophlebitis of upper extremities, unspecified cellulitis and abscess of hand, except fingers and thumb von willebrand's disease chronic factitious illness with physical symptoms 

Answer: The patient is high likely exposed to