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: vancomycin attending: chief complaint: right arm pain major surgical or invasive procedure: drainage of right arm abscess by plastic surgery history of present illness: 41 year-old male with history significant for paroxysmal atrial fibrillation, active iv drug use, recurrent bacteremia, s/p spinal fusion surgery and total hip replacement, who is transferred to general medicine floor from the sicu s/p right arm debridement for an abscess, also with mrsa bacteremia and lower back pain. the patient had a complicated medical course following a fall in , including t10-l3 fusion, iliac crest bone graft, orif right femur, and left total hip replacement complicated by mrsa septic hip requiring further surgical intervention. patient also has had recurrent bacteremia, including uncomplicated enterococcal picc-associated bacteremia in . he was admitted to sicu under the plastics service for sepsis and right arm abscess, initially suspected to be necrotizing fasciitis. past medical history: 1) l thr (due to traumatic osteoarthritis - fell off ladder), l hip mrsa prosthetic joint infection with bacteremia, s/p explant , multiple washouts, spacer placement, 2) ex-lap with resection of his small bowel, 3) orif r femur, 4) t10-l3 fusion, transpedicular decompression, at t12, multiple laminotomies, 5) right iliac crest bone graft, 6) h/o polysubstance abuse, etoh, cocaine 7) depression, s/p multiple suicide attempts: cocaine binge, radial artery laceration/percocet overdose 8) svt after washouts, responded to dilt 9) h/o gi bleed in the setting of thrombocytopenia from vancomycin, improved with stopping vanco, refused colonoscopy social history: mom died while pt hospitalized for initial fall. h/o incarceration disability. tobacco 1.5 ppd, continues to smoke. etoh, crack cocaine, opiate use in past. active ivdu. family history: nc physical exam: after transfer from sicu to medical floor: vs: 99.4 132/80 84 16 98% on ra gen: alert, lying supine, visibly distressed and moaning from pain, shouting at medical staff heent: moist mucus membranes cv: regular rhythm, rate 80s, no murmurs appreciated resp: diffuse anterior and lateral wheezing and soft rhonchi; posterior exam limited due to position back: difficult to assess due to supine position abd: soft, nontender, nondistended ext: right dorsomedial forearm with open debridement, mostly wrapped with gauze ; no lower extremity edema neuro: limited due to pain pertinent results: admission labs: wbc 18.5 / hct 25.5 / plt 412 serum tox - negative for aspirin, etoh, tylenol, bdps, barbiturates, and tcas na 130 / k 3.8 / cl 97 / co2 19 / bun 40 / cr 2.3 / bg 132 lactate 1.2 discharge labs: wbc 7.9 / hct 26.8 / plt 577 na 140 / k 3.6 / cl 100 / co2 29 / bun 9 / cr 1.2 / bg 94 microbiology: blood cx = mrsa urine cx negative wound swab - mrsa, prevotella 12/2,3,4,5, blood cx negative right hip aspirate cx negative studies: unilat up ext veins us right 1. no evidence of right upper extremity dvt. 2. complex fluid and swelling along the right forearm underlying area of redness and swelling. known deep tissue air is better visualized on recent radiograph. forearm (ap & lat) right impression: large amount of subcutaneous and deep soft tissue air. these findings are concerning for necrotizing fasciitis. chest (single view) impression: low lung volumes. mild right pleural thickening vs trace right effusion. tte (complete) suboptimal image quality. no echocardiographic evidence of endocarditis but study limited technically. normal global biventricular systolic function. aortic root dilation. ct t / l spine 1. prevertebral soft tissue density at l3-4 of uncertain chronicity as there is no prior postoperative cross-sectional imaging for comparison. infection cannot be excluded. 2. limited evaluation of the spinal canal due to streak artifact from spinal fusion hardware. ct does not provide intrathecal detail comparable to mri. 3. unchanged l1 vertebral body fracture. 4. layering right pleural effusion. tee no echocardiographic evidence of endocarditis. mr t and l spine 1. fluid collection identified at the l2/l3 intervertebral disc space, posteriorly, causing anterior thecal sac deformity, likely consistent with an epidural phlegmon, measuring approximately 7 x 28 mm in size. associated inflammatory changes noted at the intervertebral disc space and vertebral bodies at l2/l3, which are worrisome for early changes possibly related with discitis/osteomyelitis, please correlate clinically. multilevel disc degenerative changes throughout the lumbar and thoracic spine as described above, more significant at t6/t7, t7/t8, and t8/t9. 2. compression fracture at t12 vertebral body is again identified, apparently unchanged since the most recent ct, dated with mild posterior retropulsion. 3. lumbar disc degenerative changes noted at l3/l4 and l4/l5 levels with narrowing of intervertebral disc spaces, articular joint facet hypertrophy, causing bilateral neural foraminal narrowing at l4/l5 level. 4. status post posterior fixation of the thoracic spine with laminectomies from t11 through l1 level. 5. right pleural effusion and possible left lung basal consolidation as described above. brief hospital course: 41 year old male with recurrent mrsa bacteremia, active iv drug use, paroxysmal atrial fibrillation, history of spinal fusion surgery t10-l3 and left total hip replacement, who presented with with right arm abscess, mrsa bacteremia and lower back pain. after the patient was found to have fluid collections surrounding his spinal hardware that would require ortho spine surgery, he left against medical advice but was accepted by the rehab facility on a prolonged antibiotic regimen, with the understanding that he would return for surgery in a few weeks when ready. 1. right arm abscess patient presented with right arm pain and swelling s/p injection drug use. ultrasound of arm showed no dvt but complex fluid and swelling along the right forearm. xray showed large amount of subcutaneous and deep soft tissue air, concerning for necrotizing fasciitis. the patient was taken emergently to surgery by plastics who noted that there was no necrotizing fasciitis but drained the abscess. wound cultures initially grew mrsa and gram negative rods, so the patient was started in intravenous daptomycin, clindamycin, and zosyn, per infectious disease team recommendations. the clindamycin was used for a synergistic effect against mrsa for its ability to reduce the production of exotoxins by staphylococci. per id recommendations, the clindamycin and the zosyn were discontinued after a few days. metronidazole was started on the evening of per oral for a total of seven days with prevotella was found growing from the wound in addition to mrsa. for control of his right arm wound post surgically, the plastics surgery team continued to follow the patient. the wound was dressed with wet to dry dressings and dakins; the patient should be started on a wound vac, but he refused this treatment option. he should be continued on wet to dry dressing changes and follow up in clinic in . 2. mrsa bacteremia the patient has a history of recurrent mrsa bacteremia in the setting of active iv drug use. a transthoracic echo showed no evidence of vegetations, though the image quality was suboptimal. the patient initially refused tee, but eventually agreed to it; tee showed no evidence of vegetations as well. he does have a fluid collection in his left hip, as seen on imaging, where he has recently had hardware from a hip replacement and now has an antibiotic spacer. patient was initially unable to tolerate imaging of his spine due to extreme pain with movement, particularly transfers; initial mri and ct of lower spine were of poor quality. patient was ultimately placed under general anesthesia for an mri of his thoracic and lumbar spine, which showed large infected fluid collections surrounding spinal hardware. the patient requires surgical removal of his spinal hardware in two surgeries, one to work on the anterior and one for the posterior sides of the spine. the patient refused to have surgery at this time. he prefers to wait until after and the new year and will have surgery after that time. he knows and respects dr. , the ortho spine surgeon, well; he would only stay to have the surgery during this admission if dr. insisted that this was the only option. dr. felt that the patient should have the surgery sooner than later, optimally during this admission, but agreed to do the surgery at a later time if the patient preferred and to send the patient back to rehab on iv antibiotics in the meantime; he will follow up with the patient in his clinic next week. the patient refused to have a ct-guided drainage of the fluid collection at this time as well; he preferred to just wait "until the new year" to have the surgery by dr. . the patient has been afebrile for multiple days, so a picc line was placed, and the patient will continue on iv daptomycin daily indefinitely until he has the surgery; the daptomycin should continue for 6 weeks at minimum. the patient will also continue on oral metronidazole for five more days to treat the prevotella in the arm wound. the rehabilitation facility from which he came will take him back under strict monitoring for drug abuse. he will follow up in clinic with dr. next week and in infectious disease clinic with dr. next friday . he will need to have his bun/creatinine, cbc with diff, and ck checked weekly and faxed to dr. office. 3. back pain patient has chronic back pain and is s/p spinal fusion t10-l3; the pain is likely worsened by the infectious fluid collections surrounding his spinal hardware. the patient was placed on a ketamine drip, with the help of the chronic pain team, while on the surgical service to help manage for pain control in addition to per oral and intravenous dilaudid, fentanyl patch, gabapentin, and diazepam. once the patient was transferred to the general medical service, the chronic pain team was officially consulted to help with pain management. the ketamine drip was weaned slowly, and the dilaudid dose was increased to 8mg every four hours as needed, as the patient stated he was taking prior to admission. his gabapentin dose was increased slowly to his apparent home dose of 300mg tid, which can further be increased slowly to 600mg tid if needed, per chronic pain team. the diazepam is a home medication, which the patient only uses once every couple of days for back spasms. 4. psychiatric issues patient with a reported history of bipolar disorder and suicidal attempts in the past. similar to previous hospitalizations, he was verbally abusive to nursing staff and exhibiting bizarre behavior, including chewing through his central venous line. psychiatry was consulted and recommended clear limits with pain medicines, avoiding benzodiazepines which could have a paradoxical effect, and starting seroquel 25 mg tid as needed for agitation as well as prozac 20 mg daily. the seroquel did work very well to keep the patient calm but appeared to make him more sleepy than usual. after patient was told that he had infected fluid collections around the hardware in his spine and would need definite surgical removal of the hardware, he refused surgery. he was initially upset and agitated, threatening to leave against medical advice without any explanation as to why he did not want surgery. the risks of no surgery or delayed surgery were explained to him, including possible paralysis and possible death. the patient appeared to understand these risks. psychiatry was called again to assess the patient and felt that he had capacity to make his own decisions; patient was completely oriented and showed no signs of delirium-- he understood his options and the possible consequences of his decision. he expressed again to the medical team that he "just wanted a break." he was allowed to leave against medical advice after a picc line was placed and a plan for iv antibiotics and close followup was made. the patient does have a history of active iv drug use and will need to be monitored very carefully with a picc line in place while at the rehab facility long term. 5. paraphimosis after transfer to the general medical service, patient was noted to have some edema of his foreskin which was pulled back tightly around his penis. the patient did complain of some pain, but the head of the penis was still pink. the medical team and the patient were unable to reduce the paraphimosis. the paraphimosis was ultimately reduced by urology. 6. paroxysmal atrial fibrillation patient was intermittently treated with iv diltiazem for atrial tachycardia, likely atrial fibrillation, and responded well to it. he was started on per oral diltiazem in sicu per cardiology recommendations and continued on it for the rest of his hospitalization. given that his chads-2 score was 0, he was recommended to consider starting aspirin for anticoagulation once his surgical plan was confirmed. 7. acute renal failure patient's baseline renal function was about 0.8-1.0. he was noted to have an elevated creatinine to 2.0-2.9 on previous admission for mrsa bacteremia, and he had presented to the surgical service with an elevated creatinine of 2.3 on this admission. acute renal failure was of etiology, but creatinine trended down to 1.2 by the time of discharge. 8. rash patient did have patches of blanching erythematous macular rash on bilateral lower extremities, asymmetric, while on the floor. he denied pruritis and pain with the rash, but it slowly darkened and resolved with a few days. the rash appeared to be a contact dermatitis. 9. loose stool patient did have some episodes of loose stools, despite high narcotic regimen, likely antibiotic associated diarrhea. he did not have a leukocytosis and has been afebrile, but a c difficile toxin test was checked and was negative. medications on admission: fentanyl patch 50mcg/hr 1 patch q72h valium 5mg qhs and q6-8h prn dilaudid 8mg q4h iron 325qd gapapentin 300mg tid dilt 30mg po qid omeprazole 40mg qd lasix 20mg qd colace 100mg qd discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 4. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 6. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 7. daptomycin 500 mg recon soln sig: seven hundred (700) mg intravenous q24h (every 24 hours). 8. quetiapine 25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for agitation / insomnia. 9. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 5 days. 10. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for for back spasms only (use seroquel for agitation. 11. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 12. hydromorphone 4 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 14. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day): please hold for diarrhea. 15. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 16. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 17. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 18. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 19. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 20. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fe . discharge disposition: extended care facility: roscommon discharge diagnosis: primary diagnosis: mrsa bacteremia infected spinal hardware right arm abscess secondary diagnoses: chronic pain paroxysmal atrial fibrillation depression discharge condition: alert, oriented x3 pain controlled discharge instructions: mr. , you were admitted to the hospital because you had a bad infection in your right arm which had gone also to your bloodstream. you were started on antibiotic treatment for this infection. you were found to have infected fluid collections in the hardware in your spine; this hardware needs to be surgically removed as soon as possible. you did not wish to have this surgery at this time, so you decided to sign out of the hospital against medical advice. as you are aware, delaying surgery could increase your risk for worsened infection in your spine; if the fluid collections get larger, you could become paralyzed. there is also the risk that the infection could again spread to your bloodstream and infect other parts of your body, including your heart; there is the risk that you may die before coming back for surgery. prior to discharge, you understood these risks and signed the paper to leave against medical advice, as the medical team strongly felt that you should not leave the hospital at this time. it is very important for you to continue on the intravenous antibiotics prescribed to you by the medical and infectious disease teams in the hospital until you are able to have the surgery. you should return for followup in ortho spine clinic next week. please do not inject any more iv drugs because this puts you at risk for another infection. you will be continued on iv antibiotics through a picc line at rehab. the following important changes have been made to your medications: - you are starting the antibiotic daptomycin intravenously daily indefinitely, which should be continued at least until you have the surgery to remove the infected hardware in your spine - you were started on fluoxetine, which is an antidepressant which will take a few weeks to start to help - you were started on metronidazole antibiotic for your right arm wound to be continued for five more days - you were also started on diltiazem per oral 30mg four times per day to control your heart rate. this medication can later be changed to a once daily medication by your primary care doctor please seek immediate medical attention if you begin to experience fevers/chills, if you become incontinent of urine or stool, if your legs become weaker, or if you experience any other symptoms concerning to you. followup instructions: it is extremely important that you keep all of your followup appointments because you have a very bad infection around your spine. please be sure to follow up in ortho spine clinic next week with dr. at 4pm building, please also follow up in infectious disease clinic. provider: , md phone: date/time: 11:30 please follow up in plastic surgery clinic in ; you should call the following number to make the appointment. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart other incision with drainage of skin and subcutaneous tissue nonexcisional debridement of wound, infection or burn transfusion of packed cells other immobilization, pressure, and attention to wound diagnoses: tobacco use disorder acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation depressive disorder, not elsewhere classified sepsis chronic kidney disease, unspecified cellulitis and abscess of upper arm and forearm cocaine abuse, episodic rash and other nonspecific skin eruption surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation hip joint replacement infection and inflammatory reaction due to other internal prosthetic device, implant, and graft arthrodesis status methicillin resistant staphylococcus aureus septicemia redundant prepuce and phimosis 

Answer: The patient is high likely exposed to