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: iodine-iodine containing / tape "x10yd / amiodarone attending: chief complaint: perforation of small bowel at the site of the ileostomy with purulent peritonitis. major surgical or invasive procedure: laparoscopic loop ileostomy hemorrhoid banding exploratory laparotomy, takedown of loop ileostomy, small bowel resection, creation of end ileostomy and mucous fistula. history of present illness: the patient is a 64-year-old woman with a previous medical history significant for crohn's disease. she presently has evidence of a stricture in the distal terminal ileum, and because of that, the patient recently underwent laparoscopic creation of a diverting loop ileostomy. it should be added that the patient had this more conservative surgical treatment rather than a cecal resection because of poor heart condition and severe copd, both of which were considered contraindications for more extensive surgical procedures. the ileostomy was created approximately 1 month ago, and since then the patient has been doing well up until yesterday when the ileostomy output suddenly stopped and the patient developed significant abdominal pain. initial imaging studies with kub and ct scan were consistent with small bowel obstruction close to the ileostomy, and there was some concern whether the patient had intraluminal content that created a mechanical obstruction. the kub and ct scan did not show any evidence of free air. the patient was initially managed with a nasogastric tube and a foley was also placed in the afferent loop of the ileostomy yielding large amount of small bowel content, whereafter the abdomen became less a tender and distended. today, however, the abdominal pain has continued and worsened, and her abdominal exam has also worsened and we are concerned of peritonitis why the patient now was taken to the operating room for exploration. past medical history: - crohn's disease first diagnosed in approximately . - history of esophagitis and a duodenal ulcer - colonic polyps - diverticulosis - intra-abdominal abscess from perforated viscous in - pulmonary embolus many years ago with ivc filter - gi bleed and rectus abdominous hematoma while on heparin - remote history of sarcoidosis - copd - right-sided astrocytoma treated with radiation - history of stroke - v-fib arrest in s/p placement of a defibrillator. - hypertension - coronary artery disease with previous pci and stent placement - congestive heart failure ejection fraction 30% in - atrial fibrillation - degenerative joint disease, worse in the back - hypothyroidism social history: lives with husband at home. he assissts her in adls. prior to this hospitalization she was ambulated independently and was able to perform advanced adls. employment - retired tobacco - remote, 27pks yrs; etoh - denies; drug use denies family history: - brain cancer grandfather - breast cancer mother - mi @ 67 grandmother physical exam: physical exam: vs:98.3, 75, 108/57, 18, 99 % ra general: alert and oriented x3, depressed mood,teary, no acute distress heent: op clear, mmm, no lesions; no cervical lad neck: supple, no lad, no thyromegaly cardiovascular: rrr, no mrg respiratory: cta bilat w/o wheezes/rhonchi/rales back: no spinous process tenderness, no cva tenderness gastrointestinal: +bs, soft, mild ttp, non-distended, mucus fistula, ostomy - pink musculoskeletal: moving all extremities, no joint swelling or effusion lymph: no inguinal lad skin: midline wound packed w/granulation tissue, no purulence, r picc line no erythema or ttp pertinent results: admission labs: wbc-7.7 hgb-10.9 hct-34.4 mcv-88 plt ct-369 neuts-68 bands-2 lymphs-18 monos-8 eos-3 pt-14.9 ptt-22.5 inr-1.3 glu-119 bun-9 cr-0.9 na-140 k-3.0 cl-102 hco3-27 ca-8.8 ph-3.5 mg-1.9 alt-13 ast-17 alkphos-33 totbili-0.6 lipase-15 albumin-3.5 ctropnt-<0.01 crp-19.5 04:11am blood esr-0 urine color- appear-cloudy sp -1.020 blood-sm nitrite-neg protein-30 glucose-neg ketone-10 bilirub-neg urobiln-neg ph-5.5 leuks-neg rbc-7* wbc-3 bacteri-few yeast-none epi-0 urine urean-612 creat-144 na-31 k-59 cl-97 uric ac-78.0 osmolal-578 microbiology: mrsa screen : no mrsa found blood culture : mrsa+ blood culture : negative blood culture : negative urine culture : +yeast >100,000 catheter tip : no growth radiology: abdominal xr : small bowel obstruction, similar to prior, without free air. ct abdomen/pelvis w/contrast : 1. persistent small bowel obstruction upstream of ileal stricture with associated stranding and mesenteric lymphadenopathy, suggestive of possible acute on chronic inflammation, without evidence of abscess, fistula, or perforation. 2. moderate right and small left pleural effusions with associated atelectasis. 3. interval decrease of small abdominal ascites. 4. cholelithiasis. 5. mild anasarca. 6. diverticulosis. transthoracic echo : lvef 30%. severe regional and global left ventricular systolic dysfunction, c/w cad. mild to moderate ischemic mitral regurgitation. abdominal xr : 1. dilated loops of small bowel, likely postoperative ileus; however, small-bowel obstruction cannot be ruled out. 2, intra-abdominal free air believed to be secondary to recent laparoscopic surgery. transthoracic echo : cannot fully exclude a vegetation on the mitral valve; no vegetations seen elsewhere. moderate to severe mitral regurgitation. dilated left ventricle with moderate to severe regional and global systolic dysfunction. . tee - two mobile right atrial echodensities associated with the pacing leads consistent with vegetation (vs thrombus) as described above. ?aortic valve lambls excrecent (vs. vegetation). moderate to severe mitral regurgitation. dr notified of the results by telephone. . cxr -pa and lateral upright chest radiographs were reviewed in comparison to . the pacemaker leads terminate in expected location of right atrium and right ventricle. the right picc line tip is at the level of cavoatrial junction. cardiomediastinal silhouette is stable. small amount of right pleural effusion cannot be excluded. lungs are essentially clear. . kub -impression: no obstruction or free air. . echo - severe focal lv hypokinesis consistent with cad. moderate to severe mitral regurgitation, likely due to leaflet tethering. compared with the report of the prior study (images unavailable for review) of , the findings are probably similar. . kub - impression: no obstruction or free air. 11:31am lactate-1.9 11:20am glucose-119* urea n-9 creat-0.9 sodium-140 potassium-3.0* chloride-102 total co2-27 anion gap-14 11:20am estgfr-using this 11:20am alt(sgpt)-13 ast(sgot)-17 alk phos-33* tot bili-0.6 11:20am lipase-15 11:20am ctropnt-<0.01 11:20am albumin-3.5 calcium-8.8 phosphate-3.5 magnesium-1.9 11:20am wbc-7.7# rbc-3.93* hgb-10.9*# hct-34.4* mcv-88 mch-27.6 mchc-31.5 rdw-17.1* 11:20am neuts-68 bands-2 lymphs-18 monos-8 eos-3 basos-0 atyps-1* metas-0 myelos-0 11:20am hypochrom-2+ anisocyt-normal poikilocy-1+ macrocyt-normal microcyt-normal polychrom-occasional ovalocyt-1+ 11:20am plt smr-normal plt count-369 11:20am pt-14.9* ptt-22.5 inr(pt)-1.3* brief hospital course: 64 year-old woman with crohn's disease, recent admission for a flare and bowel ischemia on ct, s/p high dose steroids, discharged on reportedly tolerating po who then re-presented with bilious emesis, inability to take po and malaise within 48 hours. she was felt to have failed the trial of po steroids, and was restarted on iv high dose steroids. ngt was placed, with good effect, and decompressed the patient. she was initially admitted to the icu for hypotension, and was later transferred to the medical floor. she had an sbo that was attributed to a stricture in the mid/distal ileum that had superimposed inflammation. initially managed with steroids. tpn started on . the patient also had significant edema in her legs, arms, and breast--more prominently on the left side. diuresis given with small dose lasix with good effect and not resulting in hypotension. on she underwent a diverting loop ileostomy with dr. . post-op, the patient was transferred back to the icu for management of post-op hypotension. pressors were used for a short duration of pressors and iv fluids. late afternoon on , the patient was returned to the medicine floor with stable blood pressure. on the floor, she was continued on tpn and allowed to trial clear diet which she tolerated fairly well. she continued to have significant edema that was causing her great discomfort. lasix was restarted at the same dose as was used pre-op to attempt to reduce the edema that was still present in her legs, arms, and breast--more so on the left side. ectopy noticed on telemetry, but metoprolol not titrated up given lower sbp in 90's and hr in 40's. on the evening of , the patient was in afib with rvr. given that her sbp was in the 90's, she was transferred back to the icu for further management. in the icu, ivf were given to the patient to raise the blood pressure. metoprolol was up titrated to try to achieve better rate control, but later discontinued and switched to digoxin. blood cultures drawn revealed a new bacteremia, likely picc-associated. organism isolated is mrsa. tte was not conclusive in ruling out valve vegetation, so tee was performed which revealed vegetations on her icd lead. . by problems: 1. mrsa picc-associated bacteremia, endocarditis of intracardiac device: id and electrophysiology were consulted. given the clearance of blood cultures, lack of fevers or significant leukocytosis the patient was treated conservatively as removal of her lead would be difficult given that it is an icd lead and that it is several years old and may would require a thoracotomy (per dr. . she was treated with vancomycin, rifampin and gentamycin. however on she developed atn from the gentamycin, and antibiotics were held pending her renal function improving. she is being sent home on vancomycin and rifampin and will need to follow-up with the clinic (scheduled) and receive safety labs through the duration of her course, which will be completed on . pt underwent repeat echo on that was stable. 2. small bowel obstruction acute on chronic crohn's flare: medically treated at first but given recurrence a diverting loop ileostomy was performed. this was complicated by post op hypotension which required an icu stay and use of 1 pressor. she was able to be weaned from the pressor and sent to the regular medical floor. her sbo was definitively treated with this surgical procedure. 3. lower gi bleed/crohns disease/hemorrhoidal bleeding: this occurred on while on prednisone 40mg daily. she had maroon stools without blood clots, hct remained stable and the source was likely a stricture related to her crohn's disease. there was no bleeding into the ostomy bag. the bleeding continued despite treatment with mesalamine. on the nurse noted the mesalamine being excreted in the ostomy bag, and her mesalamine was changed to enema which was given via the ostomy, as well as adding cortifoam enemas via the ostomy. a flexible sigmoidoscopy was performed which noted grade 3 hemorrhoids, which were banded on by the colorectal surgery team. this resolved the bleeding for the most part. on to pt reported small amounts of brbpr, but received 1 unit prbcs and this resolved. given ongoing irritation of her hemorrhoids her cortef enemas were discontinued. given concern that mesalamine was contributing to her renal failure this was also discontinued. she is being discharged on a prednisolone taper with close follow-up with dr.. 4. atrial fibrillation with rapid ventricular response: as her blood pressures improved her beta blocker was up titrated up and she was started on digoxin with a load of 0.5mg daily x 2 days then on digoxin 125mcg daily. her digoxin level remained wnl at 0.6-0.7 despite the occurrence of renal failure. the level should be checked weekly until renal function is stable. on per cardiology digoxin was no longer needed. 5. anasarca and asymmetric breast edema: related to steroid use in the setting of systolic congestive heart failure with an ef of 30%. steroids were weaned post operatively and she was diuresed initially with bumex 0.5mg po daily. l breast swelling was evaluated with mammogram and ultrasound and found to be subcutaneous edema without other underlying pathology. she was seen by md from breast surgery and he diagnosed her with truncal lymphedema related to total body fluid overload and stated the recovery is a slow process but it should recovery with tapering of steroids and diuresis. 6. depression/anxiety: psychiatry was consulted as the depression and anxiety became overwhelming and the patient was unable to participate in her care. she was initially managed with ativan, and celexa was then added. subsequent to this, her ativan was changed to clonazepam with excellent results. pt was followed by social work. she was also provided with daily encouragement and support. 7. acute renal failure, acute tubular necrosis thought to be due to gentamycin toxicity vs. salicylate toxicity. renal function slowly improved with discontinuation of gentamycin and mesalamine, and then plateaued at 1.7 prior to discharge, thought to be secondary to mild dehydration for which she was encouraged to increase her po intake. she was also started on imodium and banana flakes to decrease fluid losses through her ostomy. if her renal function does not improve following discharge she should be referred to nephrology for further evaluation. 8. stoma prolapse on evening of . this was reduced at the bedside successfully with sugar. this did not reoccur. surgical team explained this occurrence and significance to the family.on had increase abdominal pain, decrease stoma output. a ct scan was done that showed an sbo at loop ileostomy site. an ngt and foley catheter was placed to decompress stomach. however she continued to have abdominal pain with peritoneal signs and leukocytosis 20 k. on patient was taken emergently to the operating room and was found to have a perforation of small bowel at the site of the ileostomy with purulent peritonitis. she underwent a takedown of her loop ileostomy, small bowel resection and creation of end ileostomy and mucous fistula. a wound swab from the or grew lactobacillus and vre. ciprofloxacin and metronidazole were started on . postoperatively was on intubated and on sedatives and transferred to the . she was bolused for decrease urine output was given intravenous fluids and albumin. on was extubated, off sedation and was started 100 mg hydrocortisone iv. on decrease hematocrit from 30.5 to 22.4, transfused with 2 units red blood cell. on went into paroxysmal afib,which was rate controlled. cardiology were consulted and metoprolol dose was increased and recommended no digoxin. overnight developed paranoia, antidepressants were restarted on . on her antibiotic were transitioned to daptomycin and piperacillin/tazobactam + rifampin. she had immediate return of bowel function after surgery, the stoma is pink and protruding with liquid stool. she has been receiving intermittent intravenous fluid boluses for high ostomy output. left mucous fistula with scant drainage. she wears an abdominal binder at all times. she has been encouraged to increase her nutritional status. she is on calorie counts and ensure. ms. complains of intermittent abdominal pain which increases with movement, she has been encouraged to take her oral analgesia as needed. she is ambulating with a walker and assist. pod 7 , prelone 21 mg po taper was started and he will continue her prelone taper per her gastroenterologist dr. refer to gi note. pod 9 she had approx 50 cc of blood from rectum, a stat hematocrit was drawn,35.2 and had no further episodes and is stable for transfer to rehabilitation center. ms. will continue on her antibiotics, zosyn, daptomycin and rifampin until refer to infectious disease note for monitoring of her renal function. medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for sob. 2. atorvastatin 20 mg tablet sig: two (2) tablet po daily (daily): lipitor. 3. entocort ec 3 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po once a day: start on sunday . 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po q 8h (every 8 hours). 5. clonazepam 0.5 mg tablet sig: one (1) tablet po three times a day. 6. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 8. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual as needed as needed for chest pain. 9. oxycodone 5 mg tablet sig: one (1) tablet po three times a day as needed for pain. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day: protonix. 11. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily): spiriva. 12. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 13. valsartan 80 mg tablet sig: one (1) tablet po daily (daily): diovan. 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. loratadine 10 mg tablet sig: one (1) tablet po once a day: claritin. 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): colace. 17. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 18. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation: miralax. 19. multivitamin capsule sig: one (1) capsule po once a day. 20. mesalamine 500 mg capsule, sustained release sig: three (3) capsule, sustained release po three times a day: pentasa. 21. prednisone 10 mg tablet sig: five (5) tablet po daily (daily) for 3 days: last day . start entocort on sunday. . 22. bumetanide 0.5 mg tablet sig: one (1) tablet po twice a day. 23. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 months. 24. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 1 months. 25. metoprolol tartrate 25 mg tablet sig: one (1) tablet po every eight (8) hours. discharge medications: 1. prednisolone sodium phosphate 15 mg/5 ml solution sig: twenty one (21) mg po daily () as needed for crohn's disease: to be decreased by 2 ml (6mg) every five days. you will take 7 ml (21mg) on . you will then take 5ml (15mg) . you will then take 3ml (9mg) . you will then take 1ml (3mg) . please call dr. with any questions regarding this taper. disp:*3 week's supply* refills:*0* 2. nystatin 100,000 unit/ml suspension sig: five (5) ml po tid (3 times a day). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 4. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation qid (4 times a day). 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-4 puffs inhalation q4h (every 4 hours) as needed for wheeze. 6. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 9. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 10. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 11. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day). 12. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 13. rifampin 300 mg capsule sig: one (1) capsule po q 8h (every 8 hours). 14. white petrolatum-mineral oil cream sig: one (1) appl topical (2 times a day) as needed for dry breasts. 15. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 16. dextrose 50% in water (d50w) syringe sig: one (1) intravenous prn (as needed) as needed for hypoglycemia protocol. 17. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 18. sodium chloride 0.9 % 0.9 % parenteral solution sig: one (1) ml intravenous q8h (every 8 hours) as needed for line flush. 19. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea. 20. daptomycin 500 mg recon soln sig: 350 mg recon solns intravenous q24h (every 24 hours). 21. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q6h (every 6 hours). discharge disposition: extended care facility: - discharge diagnosis: crohn's flare ileal stricture systolic congestive heart failure edema endocarditis bacteremia anemia acute renal failure perforation of small bowel at the site of the ileostomy with purulent peritonitis. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with a crohn's flare and underwent surgery for this. you also suffered an infection of your blood stream which may have caused an infection of your implanted defibrillator lead and you are being treated with an extended course of antibiotics. a complication of your antibiotics and crohn's treatment is transient renal failure. you will be discharged to the rehabilitation center for monitoring of your renal function and management of your ileostomy, mucous fistula, abdominal wound dressing and administration of your intravenous antibiotics which will continue until . please continue to walk several times daily for your recovery. we would also like you to encourage your oral intake and continue taking your ensure supplements. you will also continue on your prednisone taper as instructed by your gastroenterologiost dr. . please call and schedule post operative an appointment with dr.. followup instructions: please call your pcp . at to schedule a follow up appointment within 1 week of discharge. please call and schedule a follow up appointment with dr. . department: div. of gastroenterology with: , md building: ra (/ complex) campus: east best parking: main garage md, procedure: parenteral infusion of concentrated nutritional substances other partial resection of small intestine closure of stoma of small intestine diagnostic ultrasound of heart colostomy, not otherwise specified rigid proctosigmoidoscopy rigid proctosigmoidoscopy exteriorization of small intestine ileostomy, not otherwise specified ligation of hemorrhoids endoscopy of small intestine through artificial stoma central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified long-term (current) use of steroids acute posthemorrhagic anemia unspecified protein-calorie malnutrition unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified atrial fibrillation other specified intestinal obstruction depressive disorder, not elsewhere classified percutaneous transluminal coronary angioplasty status hypopotassemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure hypotension, unspecified bacteremia osteoarthrosis, unspecified whether generalized or localized, site unspecified acute and subacute bacterial endocarditis personal history of venous thrombosis and embolism personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits lump or mass in breast methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site metabolic encephalopathy hypovolemia internal hemorrhoids with other complication accidents occurring in residential institution acute on chronic systolic heart failure other suppurative peritonitis infection and inflammatory reaction due to cardiac device, implant, and graft benign essential hypertension other colostomy and enterostomy complication regional enteritis of small intestine 

Answer: The patient is high likely exposed to