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: history of present illness: the patient is a 58 year old with diabetes complicated by end stage renal disease on hemodialysis, hypertension, who presents with left hip pain, fever, hyperglycemia. patient had left hip fracture and was pinned at in . however, subsequently since , patient has been complaining about pain in her hip and for unclear reasons it increased in severity on the day of admission. she denies any trauma or fall. she also reports fever to 101.9 with chills without nausea at last hemodialysis. she denies rigors, emesis, chest pain, headache, shortness of breath, cough, sputum, abdominal pain, recent antibiotics, back pain, vaginal or urinary symptoms. she also reports that her finger sticks have been elevated for the past three to four days and she complains of polydipsia. she sleeps in a chair secondary to her hip pain, but denies paroxysmal nocturnal dyspnea or orthopnea. she reports increased swelling in her legs. in the emergency department serum glucose was 663, potassium 5.9, anion gap 18 with moderate acetone in her blood. she is anuric. she was given 10 units of insulin and started on an insulin drip and received normal saline times 1 liter, morphine for hip pain. given her fever, elevated white blood cell count and left shift, she was given vancomycin times 1 gm for presumed line infection. chest x-ray was performed which revealed left pleural effusion greater than right, interstitial edema. patient received 2 liters of normal saline only because of concern about volume overload. physical examination: on admission temperature was 97.7, pulse 93, blood pressure 130/40, respirations 26, 90% in room air. in general, a middle aged female in no acute distress. heent surgical right, pinpoint on left. no jvp. mucous membranes dry. oropharynx clear. no lymphadenopathy. hc catheter in right ij, no erythema or pain. lungs clear to auscultation bilaterally except for decreased breath sounds in bilateral bases. heart regular rate and rhythm, normal s1, s2, 3/6 systolic murmur apex. abdomen soft, nondistended, nontender, normoactive bowel sounds. extremities 3+ edema on right, right lower extremity ulcer. left lower extremity with warmth and redness, shortened and externally rotated, painful to palpation. neuro exam alert and oriented times three, grossly nonfocal. laboratory data: on admission cbc wbc 18.7, hematocrit 35.0, platelets 345, 93% neutrophils, 4% lymphs, 3% monocytes, mcv 102, 3+ hypochromic, 1+ anisocytosis, 3+ macrocytosis. chem-7 sodium 125, potassium 5.6, chloride 85, bicarb 22, bun 25, creatinine 2.3, sugar 646, moderate acetones, anion gap 18. blood cultures pending. pt/inr 14.4/1.4, ptt 32.8. ekg normal sinus rhythm at 74, normal axis and intervals, in comparison with ekg on . t waves are normalized from flipped in v3 to v6, 1, 2, l, f seen on old ekg. chest x-ray left pleural effusion greater than right, interstitial edema, atelectasis. hospital course: 1. endocrine. the patient was admitted with hyperosmolar hyperglycemia. she was initially continued on an insulin drip, was not given any additional normal saline given her end stage renal disease. her chem-7 was checked q.three hours. abg was checked which revealed ph of 7.39, pco2 47, po2 100. therefore, patient was switched to her standing insulin regimen of lantus in the evening with humalog p.r.n. during meals. lantus was adjusted during her stay as initially she was hyperglycemic on 13 units q.p.m. however, she had several episodes of hypoglycemia and so lantus was decreased to her standing dose. when she was npo, lantus was halved to 7 units. her sugars remained stable throughout the remaining hospital course. 2. infectious disease. the initial blood cultures revealed four out of four bottles of methicillin resistant staph aureus. the presumed etiology included the left hip, line infection, urosepsis, cellulitis, pneumonia. patient was continued on vanco dosed according to levels for less than 15 and was started on levofloxacin to cover for pneumonia/cellulitis. as the left hip has hardware in it, we were not able to obtain an mri. ct scan of the hip was performed, looking for signs of infection and none were seen. however, given concern of possible joint infection, an ultrasound was ordered to evaluate for fluid collection in the left hip and none was visualized, so no aspiration was performed. blood cultures continued to show mrsa; therefore, a transthoracic echo was performed. patient was additionally started on flagyl for broad spectrum coverage given many possible sources to cover for possible lower extremity cellulitis. transthoracic echo was performed on , and revealed normal left ventricular systolic function greater than 55%. mitral valve moderately thickened with no discrete vegetation, more prominent than seen on prior study in 3/00. to rule out endocarditis, a transesophageal echo was performed which revealed no vegetation. given concern about possible right ij permcath infection, the hemodialysis catheter was removed on , by the surgical line service. daily blood cultures continued to be obtained and blood culture on was positive for mrsa. additionally a blood culture on was positive for mrsa. at this point the leg cellulitis had cleared. she received a 10 day course of levo and flagyl for cellulitis/pneumonia which was completed. she no longer had the hemodialysis catheter so most likely source of the infection was felt to be the left hip, given the indwelling hardware. dr. from orthopaedics evaluated patient and felt that, although surgical intervention was high risk, he agreed to do it if everyone understood the risks. a bone scan was performed which revealed increased uptake in the left femur, coccyx and left mid-clavicle. as initially pain control had been the issue, a sacral decubitus ulcer was not initially identified. when it was seen, plastic surgery was consulted and graded it as a stage 3 decubitus ulcer. patient was taken to the o.r. on and the pin hardware was removed. culture was taken of the left hip which, at the time of this dictation, is significant for mrsa. with infectious disease consult it was determined that patient will continue a six week course of vancomycin from the date of pin removal to treat her osteomyelitis. her blood cultures remained sterile following the positive blood culture. 3. orthopaedics. the patient was initially noted to have an externally rotated and shortened left lower extremity. therefore, concern was raised about possible new hip fracture. initially a portable pelvis film was performed which revealed malalignment of the femur. orthopaedics was consulted who initially felt there was no sign of infection in the left hip. they recommended total hip replacement after her acute issues of mrsa bacteremia were resolved. however, given thorough workup for infection source as above, it was determined that the left hip was the most probable source of infection. therefore, patient was brought to the o.r. on by dr. . the two screws were removed. the hip was turned into internal rotation and mild extension. the femoral neck fracture was then separated and completed and the femoral head was removed. debridement was performed of the acetabulum as well as the proximal femur. after irrigation a drain was left in and closed in layers with pds and staples for the skin. orthopaedic surgery continued to follow patient. plan is to return to the operating room for complete repair of the hip once she receives the full six week course of antibiotics to treat her osteomyelitis. 4. renal. the patient has end stage renal disease on hemodialysis. renal consult was obtained. patient continued to receive hemodialysis q.monday, wednesday and friday initially through her right ij hemodialysis catheter. on a temporary quinton catheter was placed in the right femoral vein and this was accessed until it was discontinued on when a left femoral tunneled catheter was placed by interventional radiology. 5. neuro. pain control was difficult in this patient's case. she was initially given morphine, but became oversedated and on hospital day one received an injection of narcan for respiratory rate less than 10. subsequently her medications were changed. patient was very stable on oxycontin 40 mg p.o. b.i.d. with oxycodone for break through pain until postoperatively when she became more confused and delirious, thought to be secondary to the narcotics given intraoperatively. patient remains with tolerable pain with this regimen. on patient was complaining of diplopia and increased confusion. emergent head ct was performed and this was negative for bleed. per dr. , her pcp, baseline she has waxing and mental status which is a chronic issue. her finger sticks were normal. head ct was negative. most likely secondary to transient bacteremia. 6. pulmonary. bilateral pleural effusions. repeat chest x-ray on showed a small pleural effusion. 7. heme. patient with macrocytosis, normal b-12 and folate, normal tsh. continue to monitor. she was also noted to be iron deficient and received iron in hemodialysis. 8. gi. the patient was continued on protonix and given stool regimen for narcotics. liver function tests and transaminases were checked and were within normal limits except for elevated alkaline phosphatase which was felt most likely to be secondary to bone. , m.d. dictated by: medquist36 procedure: diagnostic ultrasound of heart hemodialysis venous catheterization for renal dialysis excisional debridement of wound, infection, or burn other partial ostectomy, femur local excision of lesion or tissue of bone, femur removal of implanted devices from bone, femur diagnoses: pneumonia, organism unspecified other postoperative infection hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease cellulitis and abscess of leg, except foot bacteremia nonunion of fracture infection and inflammatory reaction due to other internal orthopedic device, implant, and graft acute osteomyelitis, pelvic region and thigh 

Answer: The patient is high likely exposed to