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: nafcillin / cefazolin attending: chief complaint: acute epidural abscess, mssa bacteremia major surgical or invasive procedure: 1. total laminectomy of l1, l2, l3, l4, and l5. 2. incision and drainage. 3. debridement. history of present illness: mr. is a 52-year-old male with medical history significant for gout involving the left ankle for 8 years, atrial fibrillation on warfarin, hypertension, hyperlipidemia, and gout, who presented in atrial fibrillation with rapid ventricular response on , and was later found to have mssa bacteremia. during the admission, he required medical icu monitoring for neurochecks and further evaluation of epidural abscess. pt initially presented to his pcp with an erythematous, painful left ankle, with concern for gout flare. when seen by his pcp, was sob and found to be in afib with rapid ventricular response. he was transferred to the ed, where the patient was evaluated by orthopedics who felt that the patient had a painful left ankle with somewhat preserved passive range of motion, and that his exam could be consistent with cellulitis of the lateral aspect of the ankle. initial labs showed inr of 7.4, lactic acid of 1, wbc 18, bun and creatinine of 44 and 0.8, ast and alt of 108 and 127, respectively, alkaline phos 297, and c-reactive of 348. he was started on ampicillin/sulbactam for antimicrobial coverage for possible cellulitis overlying gout. however, on the night of , he spiked to 102.3 and prelim cultures grew gpc's and vancomycin was added. he had x-rays of the left ankle that showed no acute fracture, and leni was negative for dvt. cta was done at that time which showed no pe, but showed pulmonary nodules. subsequently, blood cultures in bottles grew out mssa bacteria, and she was switched to oxacillin 2g iv q4hrs. tte was done, which was poor quality, but showed no vegetations. for his afib, he was treated with iv diltiazem, and subsequently switched to iv and then po dilt. imaging done at that time was concerning for an epidural collection and possibly abcess in the l2 , l3 and l4 level. the provisional report was reported by dr. , radiologist at . the patient was evaluated by the neurosurgeon dr. , who recommended that the patient be transfered the patient to as the patient requires more mri of the spine (thoracic and cervical) and a mri brain to rule out any more extensive pathology. on arrival to the micu, the patient was somnolent but arousable. he has diffuse wheezing bilaterally. he endorses back pain and neck pain. his vital signs are hr 111 bp 103/72 o2 96% 2l. the patient was subsequently stabilized in the medical icu and later transferred to the hospital medicine service. review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. past medical history: -coronary artery disease with a negative stress in -atrial fibrillation -hypertension -hypercholesterolemia -gout -depression -recent colonoscopy in -bilateral knee arthroscopy social history: - tobacco: 70 year pack hx (smoked 2ppd for 35y, quit 16 years ago) - alcohol: 5 bottles of wine/week - illicits: used cocaine 30 years ago, denies recent drug use. denies ivda. family history: father died of an mi at 72. mother died of an mi at 68. physical exam: admission physical exam: vitals: t: 98.1 bp: 103/72 p:110 r: 14 o2: 96% 2l nc general: somnolent but redirectable, oriented, no acute distress heent: sclera anicteric, mmm, perrl neck: thick neck girth cv: irregular rate, tachycardia, normal s1 + s2, no murmurs, rubs, gallops lungs: diffuse, generalized wheezes, tight air movement bilaterally abdomen: soft, non-tender, distended, bowel sounds present, ruq with incr girth than remainder of abdomen gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing. bilateral le pitting edema 3+. area of external malleolus is erythematous and outlined but erythema extends beyond borders of outline. neuro: cnii-xii intact, 5/5 strength upper extremities, strength lower extremities, able to move bilateral le off the bed but not able to resist even minimally. grossly normal sensation, gait deferred. range of motion of r ankle is normal. range of motion of r ankle- active is none. range of motion of l ankle passive motion is limited by pain discharge physical exam: vitals: general: alert and oriented in no acute distress heent: sclera anicteric, mmm, perrl neck: thick neck girth cv: irregular rate, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally abdomen: obese, soft, non-tender, bowel sounds present, gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing. bilateral le pitting edema 2+. left ankle swelling greater than right. mild pain with active and passive range of motion of the left and right ankle l>r. dp/pt pulses bilaterally neuro: cnii-xii intact, 5/5 strength upper extremities, strength lower extremities with encouragement, lower ext sensory intact pertinent results: admission labs 02:35am blood wbc-19.3* rbc-3.30* hgb-10.2* hct-29.9* mcv-91 mch-31.0 mchc-34.2 rdw-14.9 plt ct-419 02:35am blood neuts-88.9* lymphs-8.0* monos-1.3* eos-1.5 baso-0.2 02:35am blood pt-28.6* ptt-47.0* inr(pt)-2.8* 02:35am blood esr-131* 02:35am blood glucose-131* urean-43* creat-1.2 na-134 k-4.3 cl-100 hco3-21* angap-17 02:35am blood alt-91* ast-102* ld(ldh)-314* alkphos-158* totbili-1.5 02:35am blood calcium-9.2 phos-5.0* mg-2.3 02:48am blood lactate-1.2 02:48am blood freeca-1.20 pertinent interval labs: 05:24am blood wbc-9.7 rbc-2.40* hgb-7.4* hct-22.3* mcv-93 mch-31.0 mchc-33.4 rdw-16.2* plt ct-415 07:19am blood wbc-9.3 rbc-2.42* hgb-7.3* hct-22.5* mcv-93 mch-30.2 mchc-32.6 rdw-15.4 plt ct-416 05:24am blood neuts-74.5* lymphs-20.6 monos-3.6 eos-0.9 baso-0.4 06:06am blood pt-16.7* ptt-95.6* inr(pt)-1.6* 05:24am blood pt-18.1* ptt-71.6* inr(pt)-1.7* 07:01am blood esr-146* 05:24am blood glucose-94 urean-33* creat-1.5* na-143 k-4.0 cl-106 hco3-25 angap-16 07:19am blood glucose-95 urean-34* creat-1.3* na-142 k-4.2 cl-107 hco3-27 angap-12 05:44am blood ld(ldh)-314* totbili-0.7 06:55am blood alt-38 ast-60* ld(ldh)-295* alkphos-97 totbili-0.8 03:40am blood alt-32 ast-42* ld(ldh)-232 ck(cpk)-487* alkphos-79 totbili-1.3 05:44am blood hapto-559* 04:52am blood ferritn-2934* 07:01am blood crp-108.0* 02:35am blood crp-> 300 07:07pm blood vanco-23.1* imaging: records: x-ray spine : findings: lumbar vertebral heights are preserved. normal lumbar vertebral alignment is maintained. minimal decrease in intervertebral disc spaces noted, predominantly at the l1-l9, levels with anterior osteophytosis. posterior elements and soft tissues appear unremarkable. impression: lumbar spondylosis. ankle x-ray : impression: overlying cast obscures bony details. sclerotic line of the medial malleolus may represent a nondisplaced fracture if there is a history of trauma. slight widening of the medial tibial talar joint space. soft tissue swelling. results were discussed with dr. in the er. cxr : impression: low lung volumes. no focal airspace disease, or pulmonary vascular congestion. no pneumothorax. cta : findings: there are no filling defects within the pulmonary arteries and their segmental branches to suggest pulmonary embolism. there is suboptimal evaluation of the subsegmental branches. there are ill-defined densities in both lung apices, which may reflect post-inflammatory or infectious changes. there is a 4 mm nodule in the left upper lobe (image 56 of series 3), a 6 mm ground glass nodule in the right upper lobe (image 45 of series 3), and a 5 mm nodule in the right lower lobe (image 35 of series 3). there is no pleural effusion. the heart is normal in size without a pericardial effusion. there is no axillary, mediastinal, or perihilar lymphadenopathy. the aorta is of normal caliber. incidental note is made of a left vertebral artery that arises from the aortic arch. there are no thyroid nodules. the visualized stomach, liver, and spleen are unremarkable. the bony thorax is unremarkable. impression: 1. no pulmonary embolism in the main and segmental pulmonary arteries. 2. ill-defined densities in both lung apices, which may reflect post-inflammatory or infectious changes. 3. multiple 4 to 6 mm pulmonary nodules. leni : impression: no deep vein thrombosis. abdominal u/s : findings: the liver and spleen are normal in size. diffuse increase echogenicity of the liver is seen concerning for hepatic cellular steatosis. the gallbladder appears unremarkable. limited evaluation of the common bile duct which measures 6mm. the pancreas is not visualized due to rule bowel gas and patient habitus no mass of the pancreas is seen. no hydronephrosis or mass of either kidney is noted. the right kidney measures 13.9cm and the left, 15.7 cm. the ivc and aorta are not visualized impression: hepatic cellular steatosis. limited evaluation as described above. tte : this was a technically difficult study secondary to poor penetration. moderate left atrial enlargement. other chamber sizes are within normal limits. left ventricular wall thickness and systolic function overall preserved estimated at 60-65%. there are no regional wall motion abnormalities seen. trace mitral and tricuspid regurgitation are noted. there is no evidence of a significant pericardial effusion or an intracardiac mass. given the technical limitations of the study, a vegetation cannot be excluded. ekg: from ekg read (no ekg present) atrial fibrillation with rapid ventricular response possible inferior infarct (cited on or before ) abnormal ecg when compared with ecg of 07:42, atrial fibrillation has replaced sinus rhythm vent. rate has increased by 43 bpm left posterior fascicular block is no longer present st now depressed in anterior leads nonspecific t wave abnormality, worse in inferior leads t wave inversion no longer evident in lateral leads images: l ankle film (): findings: no previous images. there is diffuse soft tissue prominence about the ankle joint. there is substantial narrowing of the tibiotalar articulation, though no definite erosions are appreciated. if there is a serious clinical concern for infection, mri would be the next imaging procedure. mr w/ and w/out contrast (): impression: extremely limited study with motion; although there is no large epidural abscess seen or prevertebral abscess identified or obvious evidence of discitis or osteomyelitis seen. subtle changes within the spinal canal could not be excluded. if there is continued clinical concern, a repeat study preferably with sedation can help. mr t- and l-spine w/ and e/out contrast (): impression: heterogeneous pattern of enhancement identified in the lumbar spine posteriorly, likely consistent with an early epidural phlegmon or epidural abscess formation, extending from l2/l3 through l4/l5 levels, causing significant narrowing of the thecal sac posteriorly. there is also evidence of fat stranding and edema in the paravertebral soft tissues at l3, l4 and l5 levels as described above with loss of the muscular plane and fat on the left at l4 level. the examination is limited due to the patient habitus and epidural lipomatosis, grossly in the thoracic spine, there is no evidence of spinal cord compression or intrinsic signal changes within the thoracic spinal cord. cxr (): impression: ap chest reviewed in the absence of prior chest imaging: extremely low lung volumes are responsible for considerable anatomic distortions, including crowding of pulmonary vasculature and widening of the cardiomediastinal silhouette. nevertheless, there could be a mediastinal adenopathy though there is also undoubtedly a contribution of fat deposition. there is no focal pulmonary consolidation, but there could be mild generalized interstitial abnormality. pleural effusions are small, if any. i would strongly urge conventional chest radiographs and if serious questions of abnormality remain clarification by a chest ct scan, if that is justified clinically. no pneumothorax. tte echo (): impression: very suboptimal image quality. normal biventricular cavity sizes with preserved global biventricular systolic function. no definite valvular pathology or pathologic flow identified. if the clinical suspicion for endocarditis is moderate or high, a tee is suggested to assess the valves. micro: 7:01 pm joint fluid source: left ankle. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. ----------- 4:30 pm tissue superficial posterior paraspinal muscle addon per mcu @630pm. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and singly. reported to and read back by # . tissue (final ): staph aureus coag +. sparse growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin-------------<=0.25 s trimethoprim/sulfa---- <=0.5 s anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. brief hospital course: the patient is a 52 yo man with h/o cad, htn, a-fib (coumadin) who presented with back pain, found to have mssa bacteremia and epidural abscess s/p drainage, with a hospital course complicated by acute renal failure and hospital-acquired pneumonia, which both improved prior to discharge. # sepsis seconary to mssa epidural abscess: the patient initially presented to his internist's office and was referred to an outside hospital, prior to the diagnosis with staph bacteremia and was later with an epidural collection consistent with abcess. mri at osh and at was consistent with epidural abscess l2-l4/5. patient underwent or drainage of the abcess by ortho spine. cultures subsequently grew mssa, prompting the initial use of nafcillin. at the time of diagnosis with hospital-acquired pneumonia, the patient was transitioned to vancomycin and cefepime, but was transitioned back to nafcillin and later cefazolin for ongoing treatment of his epidural space infection. the patient initially required q4h neuro checks given risk of epidural hematoma formation, and required medical icu coverage earlier in his hospital course. after transfer to the hospital medicine service, the patient remained hemodynamically stable without any signs of sepsis. the patient remained afebrile. after he completed his course of iv vancomycin and cefepime the patient was transitioned back to nafcillin. patient subsequently developed a drug rash lattributed most likely to the nafcillin, at which point he was switched to cefazolin. the rash stabilized and slowed in its progression prior to his discharge. the patient will be discharged on a protracted course of cefazolin. he is being followed with the infectious disease specialists and they will monitor him for the length of his antibiotic coverage. # mssa septicemia: the patient initially presented with evidence of sepsis with tachycardia, to the outside hospital, in the setting of positive blood cultures with mssa. once the blood cultures were noted to be positive at osh for mssa, the patient was started on nafcillin. he was subsequently treated with vancomycin/cefepime before thansitioning to nafcillin again and then to cefazolin as noted above. tte was without signs of endocarditis. blood cultures from did reveal mssa, but later in his course, serial surveillance cultures did not show bacterial growth. arthrocentesis did not reveal clear evidence of joint space involvement. per id, the patient will require a week course of antibiotics. although there is no identifiable source for his bacteremia it is likely secondary to skin breakdown. patient has no history recently of iv drug abuse. # left leg gout: lle edema > r and erythema and tenderness. no evidence of dvt on lenis. no evidence of bacteria on gram stain of joint tap, but many negative biorefringent crystals consitent with a gout flare. colchicine was held given worsening renal function. after transfer to the medicine floor the patient had worsening left ankle pain and swelling. he also complained of right ankle and left elbow pain. presentation is consistent with polyarticular gout. patient was transitioned from 20 mg of p.o. prednisone 60 mg of p.o. prednisone. dermatology was consulted and recommended this dose change. the patient will be sent out on prednisone with a taper until his symptoms improve. a second arthrocentesis performed the left ankle to insure that he did not have a septic arthritis as he was at risk to do his bacteremia and previous arthrocentesis. the cultures remained negative after the second arthrocentesis. # afib with rvr: started on po dilt at osh after initiation of dilt gtt for afib w/ rvr. once on the medicine floor pt triggered for a fib with rvr to the 150's. once in the micu he was initiated on a dilt gtt. his dilt gtt was increased to 20 mcg/hr without adequate control of his heart rate. amiodarone was briefly started, but was discontinued as it was felt that concerting the pt to sinus rhythm would produce an increased risk of thromboembolism. amiodarone was then stopped, metoprolol boluses were initiated and dilt gtt was weaned. on transfer to the floor pt was well controlled on metoprolol 10 mg q6h iv. the patient was transitioned to 25 mg every 6 hours. he remained stable on the floor and had no episodes of rapid ventricular response. the patient was continued on a heparin drip as her main subtherapeutic from his warfarin. the patient will be sent to his rehabilitation facility with a heparin drip as he is transitioned to a therapeutic level on his current warfarin dosing. #arf: pt's creatinine increased to 4.3 from a baseline of 1.0. this was thought to be from a pre-renal etiology as the pt was diuresed with iv lasix upon presentation to the micu. in addition, he had nearly a 5-6 l ng tube output once an ngt was placed. a few muddy brown casts were seen on urinalysis. creatinine has begun to downtrend on transfer from the micu. on for the patient's urine output remained stable and his creatinine returned to almost baseline and was 1.6 and his day of discharge. #drug rash: prior to his discharge patient developed a rash on his extremities consistent with a drug rash. the development conincided with the reinitiation of the nafcillin. the nafcillin was discontinued and he was transitioned to cefazolin. the rash improved prior to his discharge to rehab. while there was concern for the potentialcross-reactivity with the cefazolin, the type of hypersensitivity reaction, as well as the desire to maintain a bacteriacidal led the team to continue with cefazolin with planned careful monitoring. the id team planned close follow-up as well, in the event that a change in gents was required, given the expected duration of antibiotics. #ileus: pt developed a post-op ileus following episdural abscess surgery. an ngt was placed and 5-6 l of output was immediately seen. pt was kept npo until he was able to pass flatus and have bm. on the day prior to transfer to the medicine floor he had three large bm's and had a significant decrease in his abdominal pain. on the floor the patient had no nausea or vomiting had regular bowel movements and tolerated a regular diet. #healthcare associated pneumonia: after the patient's surgical intervention he began to have increased harsh requirements and hypoxia as well shortness of breath and fever. the patient's chest x-ray was consistent with pneumonia. the patient initiated a course of iv vancomycin and cefepime for total 7 days. the patient's oxygen requirements were weaned quickly and at the time of his transfer to the medicine floor from the micu the patient no longer required supplemental oxygen. #anemia: postoperatively the patient received 2 units of packed red blood cells. after that time the patient's hematocrit is foley downtrend on the medical floor. he had a negative hemolysis labwork. he had guaiac negative stools. the patient was transfused and additional unit of packed red blood cells. his hematocrit stabilized around 23%. there is no clear cause for his anemia but he remained stable multiple days prior to his discharge. we are recommending that the patient has surveillance hematocrits drawn while at rehabilitation to monitor for need for transfusion if his hematocrit just below 21%. #delirium: patient had an episode of delirium on the medical icu and required intramuscular haldol. he responded well. on the floor the patient was noted to be somewhat confused at times. his opiate analgesics were weaned and the patient's sensorium cleared. the patient is alert and oriented times discharge. ================================================= transitional issues ================================================= # pulmonary nodules: monitor as outpatient, follow up --> to ensure resolution # drug rash: need to monitor for worsening or new rash. if so consider cefazolin as the source. medications on admission: medications at home: per records -indomethacin 50 t.i.d. x5 days -prednisone 20 a day x7days -coumadin 2.5mg daily -crestor 40 daily -lotrel 10/40 -citalopram 40 -amlodipine -arthrotec 75/200 -carvedilol 3.125 mg b.i.d. -fenofibrate 160 once a day -lexapro 20 daily -colchicine 0.6mg -probenecid 500mg daily . transfer meds: colchicine tablet 0.6 mg daily ibuprofen tablet 600 mg q6hrs prn pain escitalopram oxalate tablet 20 mg daily cyclobenzaprine tablet 10mg acetaminophen tablet 650 mg every 4 hours prn pain/fever diltiazem tablet 60 mg qid hydromorphone vial 2 mg every 3 hours iv prn pain oxacillin sodium vial 2gram every 4 hours iv albuterol 0.083% neb 1 neb every 6 hours neb discharge medications: 1. prednisone 10 mg tablet sig: six (6) tablet po once a day: 60mg for 5 days then 40mg for 3 days then 20mg for 3 days then 10mg for 3 days then 5mg for 4 days. 2. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 3. crestor 40 mg tablet sig: one (1) tablet po once a day. 4. lotrel 10-40 mg capsule sig: one (1) capsule po once a day. 5. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). 7. oxycodone 5 mg capsule sig: capsules po every four (4) hours as needed for pain. disp:*60 capsule(s)* refills:*0* 8. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily): hold for loose stools. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day): hold for loose stools. 12. cefazolin 10 gram recon soln sig: two (2) grams injection q8h (every 8 hours). 13. heparin (porcine)-0.45% nacl 12,500 unit/250 ml parenteral solution sig: 2200 (2200) units intravenous per hour: goal ptt 60-100 seconds; check ptt and adjust drip as needed. discharge disposition: extended care facility: discharge diagnosis: severe sepsis secondary to epidural abscess acute renal failure health care associated pneumonia atrial fibrillation 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: mr. , you were hospitalized for a severe infection in the epidural space in your back. you required surgical intervention. during your stay you developed a pneumonia and acute renal failure. you were treated with antibiotics for the back infection and pneumonia. you are being sent to the rehab with plans for multiple weeks of iv antibiotics. the infectious diease doctors be managing the antibiotics. you also required blood transfusion during your stay. you received a total of 3 units of packed red blood cells. your blood level stabilized. you were also found to have an abnormal heart rhythm called atrial fibrillation. we are treating you with medication to prevent blood clots. this will be managed by the rehab that you go to. medication changes: stop probenecid stop colchicine add prednisone stop indomethacin add metoprolol 25mg by mouth every 6 hours add cefazolin 2 grams iv every 8 hours followup instructions: name: , location: /orthopedics address: , bldg. rm 239, , phone: when: friday, :00 am department: infectious disease when: tuesday at 10:00 am with: , md building: lm campus: west best parking: garage you should also follow up in the rheumatology clinic in 5 weeks. you can call to make an appointment with dr. . procedure: imageless computer assisted surgery excision or destruction of lesion of spinal cord or spinal meninges parenteral infusion of concentrated nutritional substances diagnostic ultrasound of heart arthrocentesis arthrocentesis diagnoses: pneumonia, organism unspecified obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis cellulitis and abscess of trunk unspecified essential hypertension severe sepsis atrial fibrillation depressive disorder, not elsewhere classified lipoma of other specified sites methicillin susceptible staphylococcus aureus septicemia other and unspecified hyperlipidemia cellulitis and abscess of leg, except foot other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation morbid obesity long-term (current) use of anticoagulants paralytic ileus dermatitis due to drugs and medicines taken internally intraspinal abscess other and unspecified coagulation defects delirium due to conditions classified elsewhere acute gouty arthropathy penicillins causing adverse effects in therapeutic use other digestive system complications 

Answer: The patient is high likely exposed to