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: sulfa (sulfonamide antibiotics) / cipro / vancomycin / shellfish / haldol attending: chief complaint: lethargy major surgical or invasive procedure: tunneled hemodialysis catheter removal hemodialysis catheter insertion left internal jugular central venous catheter hemodialysis history of present illness: ms. is a 60yo female with pmhx of t2dm complicated by nephropathy (esrd on hd), retinopathy, neuropathy and peripheral vascular disease, cad, chf, presented from her rehab with lethargy and hypoglycemia. the patient was scheduled for her hd today, and her vital signs in the am were normal, although she was felt to be lethargic at her nursing home. in the ambulance on the way to hd, the patient's bg was 60, which improved to 110 after oral sugar. she was then brought to the ed for evaluation rather than going to hd. of note, the patient has chronic pruritis for which she is followed by a dermatologist, she has many excoriations. the patient's glucose was 60 on admission in the ed. this improved to 106 after a glass of oj, which also improved her mental status. she was a&ox1 at time of initial evaluation in the ed. fsgs 66 -> oral oj -> repeat 68 -> oral oj. in the ed, initial vs were: 103.5 101 113/50 16 100% at 1500. she then had a desaturation recorded at 87% at 1600, which improved to 100%. her pressure was >100 systolic until around 1900, at which point she decrease to 90 systolic and was maintained around there until 2100. her fever curve trended down so that she was afebrile at the time of leaving the ed at 22:28. o2 sat for the remainder of stay in the ed. 18g was placed at the wrist. bp per her nursing home is 90-100 systolic. the patient received 2l ns, cefepime, flagyl, daptomycin and tylenol. a cxr revealed pulmonary congestion. her abdomen was distended so a bladder pressure was obtained, which was 18mmhg. a ct abdomen was obtained, which revealed no acute pathology. nephrology was consulted in the ed, but no note was left. lactate was 1.5. per ed report, they evaluated the patient. she was admitted to the micu for concern for urosepsis due to her pressures, which is per her nursing home, hypoglycemia. on arrival to the micu, the patinet was alert and oriented x3, except not to the date but to the month and year. she reported that she had been having periods of "black outs" where she doesn't recall details over the past 3 months. she says that that happened this morning when she does not know what happened, but the next thing she knew, she was at . of note, the patient has recently had the following discontinued or changed: lantus 24u qhs increased to 26u; gabapentin increased from 300mg after hd to 400mg qid; ativan 0.5mg q8h prn anxiety was d/c'd; buproprion was d/c'd, venlafaxine d/c'd. past medical history: # cad: stemi in with occlusion of vein graft interventions: - cabg with lima -> lad and vein graft to , 25 % - stents in left anterior descending and # systolic chf, ischemic cardiomyopathy (tte with ef 25 - 30%) # pacing/icd: right-sided aicd in place () for primary prevention given ef # dm ii, eye and renal manifestations, last hba1c 9.3% ( ) # asthma # pvd # s/p left bka # s/p right 1st toe amputation # h/o left intraductal breast cancer - s/p left mastectomy in /, now question of right-sided breast cancer, which is being followed # s/p cholecytectomy social history: hospitalized at and/or rehab since . otherwise lives in . wheelchair-bound. son (nurse) is hcp, daughter also involved; a third son lives in . -tobacco history: none -etoh: rarely -illicit drugs: denies, but used marijuana in the past family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission exam vitals: t: 97.7 bp: 90/53 p: 73 r: 18 o2: 94% 3l nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: large neck. jvp not appreciated. cv: regular rate and rhythm, normal s1 + s2, no rubs. systolic murmer appreciated. lungs: no wheezes. mild crackles and coarse breath sounds bilaterally. good air movement throughout anterior lungs. abdomen: soft, non-tender, distended, bowel sounds present. gu: no foley ext: bka on left. warm, 1+ pulses. left ue fistula with very faint palpable thrill. neuro: cnii-xii intact, moving bilateral ue spontaneously. skin: excoriations throughout the dermis without signs of pus or erythema. discharge exam: vs 98 99/54 86 18 98%@4l general: alert, oriented x3, conversive heent: anicteric sclera, eomi, ncat, several healed facial excoriations neck: no jvd cv: rrr. ns1&s2. holosystolic murmur at apex resp: ctab. good air flow gi: bs+4. non-distended. edematous abdominal wall worse in dependent areas ext: rle free from edema. bka on left. lue fistula with very faint palpable thrill. pertinent results: admission labs: 04:20pm wbc-15.0*# rbc-3.51*# hgb-10.0*# hct-32.3*# mcv-92 mch-28.4 mchc-30.8* rdw-19.9* plt ct-239 04:20pm neuts-90.0* lymphs-6.5* monos-3.3 eos-0.1 baso-0.2 04:20pm glucose-57* urean-52* creat-5.2* na-127* k-5.7* cl-93* hco3-24 angap-16 04:20pm alt-15 ast-27 ck(cpk)-50 alkphos-173* totbili-1.3 04:20pm lipase-23 04:20pm ck-mb-3 04:20pm albumin-3.1* 08:40pm calcium-8.7 phos-3.3# mg-1.8 04:35pm lactate-1.5 04:55pm urine color-dkamb appear-hazy sp -1.019 04:55pm urine -tr nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-lg 04:55pm urine rbc-2 wbc-68* bacteri-few yeast-none epi-1 04:55pm urine casthy-8* . discharge labs: 07:00am wbc-11.7* rbc-2.98* hgb-8.8* hct-28.4* mcv-95 mch-29.6 mchc-31.1 rdw-21.4* plt ct-137* 08:00am pt-16.2* ptt-36.6* inr(pt)-1.5* 07:00am glucose-180* urean-29* creat-3.6* na-133 k-3.5 cl-96 hco3-26 angap-15 01:04am alt-5 ast-30 ld(ldh)-203 ck(cpk)-45 alkphos-184* totbili-1.4 07:00am albumin-3.0* calcium-8.5 phos-3.4 mg-1.9 . pertinent labs: 04:20pm ck-mb-3 03:20am ck-mb-4 02:29am ck-mb-4 ctropnt-0.25* 01:04am ck-mb-3 ctropnt-0.25* 01:45pm tsh-1.7 06:28am cortsol-24.4* 01:04am digoxin-0.4* 01:45pm digoxin-0.5* 03:14am digoxin-0.6* 03:07am type-art temp-38.1 po2-131* pco2-43 ph-7.37 caltco2-26 base xs-0 comment-axillary t 12:44pm type-art po2-75* pco2-37 ph-7.45 caltco2-27 base xs-1 . micro: culture culture, routine-pending inpatient culture culture, routine-pending inpatient culture culture, routine-pending inpatient culture, routine-pending culture, routine-pending urine culture-final {yeast} culture, routine-neg stool c. difficile dna amplification assay-neg culture, routine-neg urine culture-final {yeast} culture, routine-mssa urine culture-final {yeast} culture, routine-mssa culture, routine-mssa culture, routine-neg culture, routine-neg catheter tip-iv wound culture-mssa culture, routine-mssa culture, routine-neg urine culture-final {yeast} urine culture-final {yeast} mrsa screen mrsa screen-final {positive for methicillin resistant staph aureus} culture, routine-mssa culture, routine-mssa swab gram stain-final; wound culture-final {staph aureus coag +, staph aureus coag +} emergency . studies: ekg normal sinus rhythm. first degree a-v block. left axis deviation. intraventricular conduction defect. non-specific st-t wave abnormalities. compared to the previous tracing of intraventricular conduction defect is more marked and heart rate has increased. . cxr impression: moderate cardiomegaly and mild pulmonary edema. no evidence of pneumonia. . ct abd pelvis woth contrast small-to-moderate amount of simple ascites and anasarca may be from fluid overload. extensive atherosclerotic disease of the abdominal aorta and major visceral branches. hepatic steatosis. fibroid uterus. . cxr there is no significant change since prior exam. there is no new lung consolidation. pulmonary edema is severe. . cxr : no new focal consolidation to suggest pneumonia. stable pulmonary edema. . cardiac echo overall left ventricular systolic function is moderately depressed (lvef= 35 %). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the findings are similar. impression: no vegetations seen . ct head : no acute intracranial process . cxr : no new focal consolidation to suggest pneumonia. stable pulmonary edema. brief hospital course: 60yo female with pmhx of cad, chf, esrd on hd, t2dm, and history of chronic pruritic excoriations presented with lethargy, found to have mssa sepsis secondary to infected line vs. infected skin sores. required intermittent pressure support. course also c/b delirium toxic-metabolic encephalopathy. delirium cleared and will be empirically treated as outpt with 6 week course of cefazolin (day 1:) . # mssa bacteremia: presented with sirs criteria for leukocytosis and transient hypotension (although may have been near ). initial empiric coverage with daptomycin (vanco allergy), flagyl, and cefepime. lactate normal. on grew mssa in bottles, wound cultures grew mssa as well, and nasal swab grew mrsa. surveilance cultures 9/6 grew mssa. rij tip culture also grew mssa. urine cultures on grew yeast. cxr concerning for pneumonia, so daptomycin was swithced to linezolid, flagyl was dc'd. the patient remained afebrile and wbc trended down. she was transferred to the floor on . she was transferred back to the micu on for worsening mental status and hypotension. surveillance bcxs remained negative, but given worsening clinical picture, antibiotics were broadened to daptomycin and cefepime. dapto and cefepime started on , and per id, to be continued for 7 days, followed by 6 weeks of cefazolin for presumptive mssa endocarditis (tte showed no vegetations; tee not pursued as not within patient's goals of care). transferred back to the floor wher vs were stable oand treated for a total of 6 days with iv cefepime/dapto. switched to cefazolin 2g post hd (day 1:). cultures negative to date. . #hypotension: possibly sepsis, possibly related to hd. pt. was occasionally on low-dose norepinephrine. this was discontinued on and patient was started on midodrine 10mg tid. pt. tolerated hd from hemodynamic standpoint on this regimen. midodrine started in an attempt to wean off pressors. at rehab, pressure should be monitored ( pressures ~80's systolic) and midodrine weaned as tolerated. . # ams: likely multifactorial including sepsis, hypoglycemia, polypharmacy, and underlying psychiatric condition. the patient's mental status fluctuated from lethargy at presentation to evening lucidity and profound am somnolence, as well as hyperactive delirium with paranoia and hallucinations. abg was not conerning for hypercarbia, and was not hypoglycemic during admission and without signs active infection. per psych recs, zyprexa 5mg in , plus 10mg qhs dose. remained lucid while on the floor. hydroxyzine was held in an attempt to limit sedating medications, however, may be slowly restarted at rehab facility. . # hypoglycemia: most likely due to infection. the patient is taking insulin with only a slight increase in her lantus from 24u to 26u prior to admission, otherwise is on a fairly moderate humalog sliding scale. she denies changes in diet. bg monitored 5x/day, the patient ate regular meals. lantus was held and pt.'s glucose was adequately controlled with regular insulin sliding scale, however, became hyperglycemic near day of discharge. low dose lanutus restarted at 10u qday, and will need to be uptitrated. . # ckd stage v on hd: patient received make-up hd on hospital day two, then line removed. hd line was replaced on and pt. resumed intermittent hd. . #acute on chronic systolic chf: euvolemic on admission with o2 requirement but it is minimal. digoxin was held, and a digoxin level was 0.6. she had a 1500cc fluid restriction and i/o's trended. was volume overloaded after transfer to floor, however, after several uf hd sessions became euvolemic. ef on 35%. thought that esrd contributed to acute on chronic systolic heart failure. . # cad: no cp or anginal symptoms at this time. continued aspirin, simvastatin. plavix has been discontinued per records and . . # dm ii, uncontrolled with complications: multiple complications although control has improved with most recent hga1c at goal. likely significant contributor to multiple medical problems. sugars difficult to control, and will need to be monitored and insulin adjusted as necessary. . # depresion: seen by psychiatry after reporting si and depressed mood. restarted venlafxine at discharge with the plan to continue at 37.5mg through . then increase to 75mg daily. holding wellbutrin, but may restart on . also started on zyprexa 5mg tid and 10mg hs. daily ekg to monitor qtc. . # goals of care: spoke with hcp (son and daughter regarding goals of care given patient's multiple hospitalizations. pt and family reaffirmed that she is dnr/dni. patient expressed that she is "tired of this" and would rather be home than in the hospital. family and patient stated that they would like for her to be treated with iv antibiotics for the 6 week duration suggested by id. options of obtaining tee to look for endocarditis and for consideration of pacemaker removal given her bacteremia were discussed. after discussion of risks and benefits, family decided not to pursue either. they stated that they would like to have hospice care consult initiated at rehab. if re-hospitalization is recommended during her rehab stay, the family should be for a discussion before patient is again admitted to the hospital. on day of discharge pt requested to go over goals of care again, citing "i want my family to know that moms ok". unfortunately her son was not able to be , and pt agreed to have discussion at ltac. . transitional issue: #started midodrine on transfer out of micu, pressures need to be monitored, midodrine weaned as appropriate. #restarted effexor at 37.5mg. will need to increase dose to 75mg qday on . restart wellbutrin on #held scheduled lantus due to initial hypoglycemia, however restarted on day of discahrge hyperglycemia. will need to be closely monitored and titrated up as necessary. #will need follow-up scheduled with pcp days #will need to treat for 6 weeks with cefazolin 2g post hd, and 3g post hd on long cycle (tues of t,th,sa schedule) #will need weekly cbc w/ diff, esr/crp, to be drawn at hd medications on admission: preadmission medications listed are correct and complete. information was obtained from . 1. gabapentin 400 mg po qid start: q48h give only on days after hd. in the evening. 2. docusate sodium 100 mg po bid hold for loose stools 3. digoxin 0.0625 mg po every other day on non-hd days 4. calcium acetate 1334 mg po tid w/meals 5. aspirin 81 mg po daily 6. ascorbic acid 500 mg po daily 7. nephrocaps 1 cap po daily 8. lidocaine 5% patch 1 ptch td daily apply to back 9. metoprolol tartrate 12.5 mg po bid on non hd days. hold for sbp < 90, hr < 55 10. pantoprazole 40 mg po q12h 11. senna 2 tab po hs hold for loose stools 12. simvastatin 40 mg po daily 13. hydroxyzine 25 mg po q8h:prn pruritis 14. guaifenesin ml po q6h:prn cough 15. oxycodone (immediate release) 5 mg po q4h:prn pain hold for somnolence, rr<12 16. glargine 26 units bedtime insulin sc sliding scale using hum insulin preadmission medications listed are correct and complete. information was obtained from . 1. gabapentin 400 mg po qid start: q48h give only on days after hd. in the evening. 2. docusate sodium 100 mg po bid hold for loose stools 3. digoxin 0.0625 mg po every other day on non-hd days 4. calcium acetate 1334 mg po tid w/meals 5. aspirin 81 mg po daily 6. ascorbic acid 500 mg po daily 7. nephrocaps 1 cap po daily 8. lidocaine 5% patch 1 ptch td daily apply to back 9. metoprolol tartrate 12.5 mg po bid on non hd days. hold for sbp < 90, hr < 55 10. pantoprazole 40 mg po q12h 11. senna 2 tab po hs hold for loose stools 12. simvastatin 40 mg po daily 13. hydroxyzine 25 mg po q8h:prn pruritis 14. guaifenesin ml po q6h:prn cough 15. oxycodone (immediate release) 5 mg po q4h:prn pain hold for somnolence, rr<12 16. glargine 26 units bedtime insulin sc sliding scale using hum insulin discharge medications: 1. ascorbic acid 500 mg po daily 2. aspirin 81 mg po daily 3. digoxin 0.0625 mg po every other day on non-hd days 4. docusate sodium 100 mg po bid hold for loose stools 5. lidocaine 5% patch 1 ptch td daily apply to back 6. metoprolol tartrate 12.5 mg po bid on non hd days. hold for sbp < 90, hr < 55 7. nephrocaps 1 cap po daily 8. senna 1 tab po bid hold for loose stools 9. heparin flush (1000 units/ml) 4000- unit dwell prn line flush catheter (tunneled 2-lumen): nurse only: withdraw 4 ml prior to flushing with 10 ml ns followed by heparin as above according to volume per lumen. 10. hydrocerin 1 appl tp tid apply to excoriations on arms 11. hydrocortisone (rectal) 2.5% cream 1 appl pr daily prn rectal pain 12. midodrine 10 mg po tid 13. mupirocin cream 2% 1 appl tp apply to arm excoriations 14. olanzapine 5 mg po hs:prn agitation please hold for sedation or rr<10 15. venlafaxine xr 37.5 mg po daily 16. hydroxyzine 25 mg po q8h:prn pruritis 17. pantoprazole 40 mg po q12h 18. calcium acetate 1334 mg po tid w/meals 19. oxycodone (immediate release) 5 mg po q4h:prn pain hold for somnolence, rr<12 20. simvastatin 40 mg po daily 21. cefazolin 2 g iv post hd give 3g when >2 days between hd 22. glargine 10 units bedtime insulin sc sliding scale using hum insulin 23. olanzapine (disintegrating tablet) 5 mg po tid agitation hold for sedation or rr <10 discharge disposition: extended care facility: discharge diagnosis: primary diagnosis: sepsis secondary to staph aureus bacteremia (mssa) chronic kidney disease stage v on hd acute on chronic systolic congestive heart failure delirium secondary to toxic-metabolic encephalopathy insulin diabetes mellitus type ii, uncontrolled with complications hypoglycemia secondary diagnoses pruritus w/ excoriations/ diabetic dermopathy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital with a bacterial infection in your , and your sugar was low. you were treated with antibiotics through your veins. we believe the infection was due to your hemodialysis catheter, so it was pulled during your time in the intensive care unit. a second hemodialysis catheter was placed after your cultures were no longer growing bacteria. at discharge you demonstrated no signs of bacterial stream infection. because you did not want to get a transesophageal echocardiogram or have your aicd pulled we want you to take cefazolin for the next 6 weeks. this should adequately treat any infection of your heart or aicd, if there is one there. your pressure was difficult to control and at times it became very low. we were concerned this may due to the infection in your , and you were treated in the intensive care unit with medication to increase your pressure. you will be continued on one of these medications, midodrine, as an outpatient. at discharge your pressure was stable. you were intermittently confused and tired during your stay at . we believe this is due to your underlying renal failure in addition to your stream infection. it also may have been due to your hydroxyzine. your hydroxyzine was stopped for this reason. your itching was not changed after stopping this, but if it worsens you should inform your pcp. discharge you were not confused and able to carry on full conversations. your sugar was difficult to control while in-house. it initially was very low, so you were taken off of standing lantus. prior to discharge your sugar was elevated, so we placed you back on 20 u lantus. your sugars should be checked at least 4 times daily in your rehab facility, and insulin should be adjusted accordingly. psychiatry visited you while you were here because of your depressed mood. they restarted you back on effexor. you will continue this at rehab, and gradually increase your dose. once you reach the maximum dose, you can then start your wellbutrin. you will need to keep your hemodialysis line in place for now. you will need to follow up with your outpatient nephrologist in order to image your fistula in your left arm. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: will need to schedule follow-up with pcp 4-8 days of discharge from the rehab facility: , lauraine e. md : you will need to follow-up with your nephrologist dr. . you need to have an outpatient fistulagram. address: , 8, , phone: fax: md procedure: hemodialysis venous catheterization for renal dialysis arterial catheterization incision with removal of foreign body or device from skin and subcutaneous tissue injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: end stage renal disease renal dialysis status urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status asthma, unspecified type, unspecified personal history of malignant neoplasm of breast polyneuropathy in diabetes depressive disorder, not elsewhere classified percutaneous transluminal coronary angioplasty status methicillin susceptible staphylococcus aureus septicemia sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease alkalosis long-term (current) use of insulin old myocardial infarction morbid obesity automatic implantable cardiac defibrillator in situ acute and subacute bacterial endocarditis kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure do not resuscitate status acute on chronic systolic heart failure below knee amputation status background diabetic retinopathy diabetes with neurological manifestations, type ii or unspecified type, uncontrolled hemorrhage of rectum and anus peripheral angiopathy in diseases classified elsewhere chronic ulcer of other specified sites diabetes with renal manifestations, type ii or unspecified type, uncontrolled suicidal ideation diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled unspecified pruritic disorder bloodstream infection due to central venous catheter 

Answer: The patient is high likely exposed to