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: patient recorded as having no known allergies to drugs attending: chief complaint: right blown pupil, slumped in the grocery store major surgical or invasive procedure: intubation, central line and arterial line placement, tracheostomy, percutaneous gastric tube placement, bronchoscopy. history of present illness: 56 yo unknown handedness female with h/o dm, mechanical valve on coumadin, afib who presents s/p slumping down in the grocery store. her daughter was with her at the time. at approximately 1:30pm she was walking in the grocery store when she slumped down, lost consciousness and became unresponsive. ems intubated her in the field, noted she had a blown right pupil, transferred her to the for furtherworkup. per the family, she has been feeling fatigued for several days, has had several episodes of "feeling as though she may pass out" but never lost consciousness. + family stressors. no other symptomatology per family - no fever/chills, cp, sob, abdominal pain, headache, nausea/vomiting, or other symptoms that the family is aware of. past medical history: 1. dm on po meds and insulin prn 2. mitral valve replacement 6 yrs ago with valve at , secondary to damage from rheumatic heart disease. cardiologist is dr. at . tricuspid valve repair . ? cardiologist records were faxed here. makers faxed a statement saying their valves are mri safe. 3. painful peripheral neuropathy for which she takes neurontin 4. hypothyroidism 5. htn vs. liver disease given nadolol on med list social history: does not work at this time, no tob/etoh/drugs per family. has 2 daughters and a son, married but seperated at this time. lives with her granddaughter whom she raised. family history: unkown physical exam: in the ed upon presentation: vitals: fs 158 134/71 heart rate 63 100% on mech vent, no temp available gen: intubated, sedated chest: cta bilaterally cv: irreg irreg rhythm with a crisp s1 (click) heard best at apex, i/vi systolic murmur. abd: obese, soft extrem: vericose veins and some overlying skin changes, spontaneously moving lower extremities neuro: mental status: sedated (for intubation). not opening eyes to voice or pain. cn: right pupil 4mm, no constriction to light. left pupil 3mm- >2mm. corneal reflex intact bilaterally sensory: decerebrate response to painful stimuli bilateral arms motor: moving lower extremities spontaneously reflexes: upgoing toes bilaterally notable changes in physical exam 2 weeks after admission: gen: tracheostomy of the neck, lying in bed skin: no breakdown on the back per nursing chest: decreased breath sounds at the left lung base anteriorly cv: irreg irreg rhythm with a crisp s1 heard best at apex abd: obese, soft, + bs, percutaneous gastric tube in place without exudate extrem: vericose veins and some overlying skin changes bilaterally ms: follows commands via right hand squeezing, attempts to open eyes when asked, nonverbal cn: right pupil is 8mm and nonreactive, left pupil is 3->2mm and sluggish, left eye is able to look downwards only, right eye - no eom. visual acuity: counting fingers. weak cough with suction. ? unable to tell if she has face droop. motor: moves right arm and right leg when instructed to do so. flacid paralysis of left arm and leg dtrs: triple reflex of the left leg, otherwise 1 sensation: extensor response of the lue to pain, otherwise withdrawls in all other extremities pertinent results: 05:09pm %hba1c-7.4* 10:03pm ck-mb-notdone ctropnt-<0.01 02:35pm glucose-195* urea n-30* creat-1.2* sodium-141 potassium-3.5 chloride-101 total co2-30* anion gap-14 02:35pm alt(sgpt)-33 ast(sgot)-31 ld(ldh)-335* ck(cpk)-107 alk phos-101 amylase-71 tot bili-1.1 02:35pm ck-mb-2 ctropnt-<0.01 02:35pm plt count-198 02:35pm pt-15.4* ptt-28.1 inr(pt)-1.6 inr upon admission: 1.6 (subtheraputic) wbc peak: 20k studies: mri/a: impression: acute brainstem and right thalamic infarct, due to vertebrobasilar occlusive disease. ct angio : 1) patient with known history of basilar occlusion status post tpa, now with improved blood flow in the basilar artery with persistent thrombus at the basilar tip. 2) the right posterior cerebral artery is not well visualized and overall caliber is small and irregular. 3) hypoplastic left distal vertebral artery with the dominant right vertebral artery supplying the basilar artery. the remainder of the intracranial circulation demonstrates no evidence of critical stenosis or aneurysms. tee on : conclusions: 1. the left atrium is dilated. the right atrium is dilated. 2. there is symmetric left ventricular hypertrophy. the left ventricular cavity is dilated. overall left ventricular systolic function is moderately depressed. 3. a bileaflet mitral valve prosthesis is present. the mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. 4. the tricuspid valve leaflets are mildly thickened. a tricuspid valve annuloplasty ring is present. 5. no definitive cardiac source of embolism identified. cxr (multiple): lll infiltrate, small pleural effusion sinus ct (): impression: diffuse sinus opacification. with the history of nasal packing the significance of this finding is uncertain. ct abd ()impression: 1. no evidence of intra-abdominal abscess or retroperitoneal hematoma. 2. patchy opacities at the left lung base with an area of consolidation could represent a pneumonic process. mri/mra (): impression: 1. the mr study of the brain reveals evolution of the previously seen infarction involving the right thalamus, medial temporal, and occipital lobes, and cerebral peduncle with evidence of prior hemorrhagic transformation. 2. evidence of chronic small vessel ischemic infarcts, which are unchanged. 3. opacification of the paranasal sinuses, as seen previously on the sinus ct of . since , there is evidence of bilateral fluid accumulation in the mastoid air cells. 4. the mr angiogram shows restored basilar flow, but still no left vertebral artery flow. cxr (): impression: 1) tip of picc is in the upper to mid svc. 2) stable cardiomegaly and mild chf, with improvement in the appearance of pneumonia. 3) small persistant opacity at the left hilum may represent residual pneumonia or prominent pulmonary vessels--followup to resolution is suggested. brief hospital course: hospital course until : 56 yo woman with h/o mechanical valve and afib on coumadin, subtheraputic, who presents with brainstem lesion findings on exam, given t-pa in ed for suspected basilar artery occlusion. mri/a confirms this diagnosis. occlusion likely secondary to subtheraputic inr and clot from afib or mechanical valve. 1. for her stroke, she was admitted to the neuro icu. her blood pressure was mainated between sbp 130-150. a head ct after the tpa was obtained and showed no bleed. a ct angio was obtained which showed a partially reperfused basilar, still with some clot at tip of the basilar. she was placed on heparin drip. she was started on a statin and recieved blood transfusions to maintain a goal hct>30. a carotid duplex scan showed a right 60-69% stenosis, normal left ica, left vertebral artery with no flow, right vertebral artery is ok. she should have a f/u duplex in 6 months. 2. during her admission to the neuro-icu she developed daily temperature spikes to a max temp of 102. culture data obtained and revealed mssa in the sputum and lll infiltrate on cxr. ceftriaxone was initially begun on but her fever persisted, so ctx was discontinued and zosyn was started on . id was consulted as she remained persistently febrile. they recommended increasing the dose of zosyn and continue to follow cx data. her a-line was discontinued and her central line was changed over a wire. all blood cx ngtd, mrsa screens negative, nasal packing discontinued (see below). 3. excessive nose/op bleeding, noted first on the night of admission after intubation in the field, worsening after starting heparin. ent was consulted. they packed her nares and then removed the packing on . she still continued to ooze from her nares and bloody secretions were suctioned from her trach and oropharynx. 4. htn: her bp regimen was ajusted multiple times throughout her course to optimize cerebral blood flow. she is currently on labetolol, captopril, lasix 5. afib: continued digoxin, beta blocker for rate control, heparin. 6. anemia: likely 2o2 nose bleed, on heparin. she was transfused on . 7. ekg changes (rapid afib, rbbb, lateral st depressions): she ruled out for mi, tele was revealing for only rapid afib, am ekg unchanged. she was betablocked for rate control. 8. mechanical mitral valve ( >: a tee was performed while she was intubated on , no clot was discovered, no endocarditis, + pfo. blood cx were ngdt. heparin was started 24 hours after t-pa was given for a goal ptt on 40-60. coumadin was initially restarted but was held secondary to op bleeding and the need for possibly surgeries. 9. hypothyroidism: she was continued on her levoxyl (home dose unknown). will need her tsh checked after her acute illness issues have resolved. 10. resp: she was intubated as she could not control her secretions, extubated on but had to be re-intubated later in the day as not able to control secretions again. a trach/ was placed on by dr. . she is now satting well on cool mist trach mask. 11. renal: her creatinine was followed and peaked at 1.3 likely secondary to a pre-renal state as her fractional excretion of urea was < 35%, she began to hemoconcentrate and her cl was rising. her meds were renally dosed. dig level checked to ensure no toxicity. during her hospitalization course an acei was added to her bp regimen to help improve blood flow to the kidneys and help in secondary stroke prophylaxis. 12. dm: while in the icu she was maintained on an insulin drip, then converted to nph and oral regimen with riss. 13. peripheral neuropathy, very painful - neurontin increased to 1200 tid 14. at one point she complained of abdominal pain, this resolved. her lfts were mildly elevated so a ruq us was obtained and showed absent gallbladder, no cbd dilation. 15. hypernatremia - resolved with free water boluses x 3 days. 16. constipation: po fleets 17. ppx: pneumoboots, ppi, replete lytes prn , pt/ot, oob, bowel regimen 18. fen: tf gastric tube pt transfered to medicine floor on . on pt became hypoxic and was trasnfered back to the icu. hospital course by problem as of : on , the patient desaturated on being turned and was transferred to the micu for further treatment. hypoxia was felt to be secondary to a combination of pneumonia and/or a blood clot plugging of airways. cta was negative for pe. a head ct showed pan-opacification of the sinuses, considered to be sinusitis. micu team called to evaluate, pt transfered to micu for desaturation. pt intubated in micu. 1. respiratory failure: bibasilar aspiration mrsa pna on vent. - mrsa in sputum on . multiple attempts to wean with rapid sequence breathing indices. pt is taking breaths on her own. bronchoscopy performed to evaluate trach placement to see if mechanical problems causing failure to wean. trach in place suggesting more central causes of failure to wean. in addition, pt producing copiuos secreations which would be very difficult to clear. pt has persistent lll pna even after completing vanc and ceftaz course, still copoius secretion. : abx coarse complete. repeat sputum cx + for mrsa suggesting colonization. changed abx to oxacillin and ceftriaxone for treatment of presumed osteo. will follow cxr to evaluate pna status. d/c'd vanc/ceftaz. id following and agreed with plan to stop vanco and ceftaz. * 2. fevers- pna sputum posititive to mrsa. neg ruq usg, c.diff, urine cx, blood cxs, tee, anca. one blood cx on + for staph non-aureus in bottle. suspected contamination, second set of cx's negative. -s/p sinus drainage by ent, aspirated + for mrsa. lines d/c'd to rule out as cause of fevers. pt only with peripheral iv's until afberile. bronch: bal showed + mrsa. - completed zoysn (ctx , then switched to zosyn for broader coverage). -- ceftaz d/c'd per id recs since no sputum cx w/ gnr. other possible infectious source is sacral decub ulcer. ?osteo. plastics following- plastics felt they were able to probe to bone on debridement suggesting stage 4 decub and osteomyelitis. - - growing gpc in blood cultures; on vanco and ceftazidime restarted. cont for 14 d course. -- gpc still two bottles, fevers better, wbc 28 yesterday now 21. holding tylenol around the clock to see what fever is (was started given high hr). felt that lp and bone bx was too invasive at this point given pt's respiratory status. decided to presume osteo based on ability to probe to bone and treat accordingly. -: id signed off. called it mrsa sinusitis and gnr pna. one more week of abx recommended. pt completed full course of abx therapy for pna. -: vanco and ceftaz d/c'd as pt received full course and started on oxacillin and ctx for presumed osteo. pt to conintue this course for an additional 4 weeks for full treatment of osteomyelitis. of note, wound cultures of decub were negative with pt on abx. 3. nstemi/a fib - found to have elevated ces on with no ekg changes. controlled hr and afib with rvr with amiodarone started on . bp and hr also controlled with lopressor. pt was already on asa, started on heparin gtt. pt's afib with occasional rvr required additional doses of iv lopressor and fluid boluses. pt restarted on coumadin and became therapeutic with goal inr between . checked inr on daily basis and adjusted dose based on inr. - kept hct >30 with transfusions as needed due to recent hx of mi. - : talked to primary cardiologist dr. , ; apprised him of situation. appreciated update. - treated with asa, heparin gtt, betablocker. - transfused to keep hct >30. - on coumadin for st. jude valve. goal inr . 4. stroke - dense neurodeficit. as per previous neuro note, the patient was to follow commands initially. become more unresponsive and f/u mri showed evolution of stroke with hemorrhage. pt now, unresponsive to commands. blown r pupil and sluggish l pupil. opens l eye to name but does not track. does not follow commands. will with draw r arm and both legs to pain. spontaneous movements of r arm and b/l legs. l arm flaccid. b/l upgoing toes. positive cough and gag with suction. -carotid duplex - r 60-69% stenosis, l ok, left vert no flow, rt vert ok. f/u duplex in 6 months. - statin d/c'd because of elevated liver enzymes and ck's. - therapeutic on coumadin 5. elevated lfts: ruq usg neg. viral serologies ebv igg pos, cmv pending. 6. mechanical mitral valve - therapeutic inr w/ coumadin. d/c'd heparin gtt . 7. hypothyroidism: levoxyl; tsh/t4 normal 8. dm: restart insulin gtt for bs in 200-300s - goal 90-120s - on lantus starting - able to stop insulin gtt - pt requiring lantus 90u qam and furhter coverage with insulin sliding scale. pt did well with this regimen. 9. afib- inr 2.2 (d/c heparin gtt) cont coumadin goal inr - changed amiodarone to 200 qd after 7 days of amiodarone 200mg . 10. peripheral neuropathy prior to admission. - holding neurotin for ? cause of fevers? 11. anemia: likely nose bleeds and chronic illness, on heparin, s/p multiple tranfusions with goal hct > 30. -hct bumps appropriately after prbc 12. stage 4 decub ulcer- consulted plastic surgery who feels that the ulcer probes to bone. presumptive osteo. on ctx and oxacillin. plastics has debrided decub again and again on . pt has been on air mattress while in icu with q2 turning. 13. psych: started celexa recommended by neuro based on location of cva. 14. pt had tube placed for nutrition. tolerating tube feeds well, at goal. pt on bowel regimen, no problems with constipation or diarrhea. also received free water boluses via . seen by nutrition for recommendations on tube feeds. 15. access- foley, - r ij placed (placed as on heparin gtt but increase risk of infection as close to trach) change foley cath today for yeast in urine. urine cx negative. - r ij d/c'd ; r picc line placed. 16. sisters- and , with family husband (separated), daughter , granddaughter . health care proxy now sister . 17. prophylaxis- protonix, iv coumadin, pt seen by pt who gave recommendations for therapy, bowel regimen, chlorhexidine mouthwash; head of bed >30 degrees. 18. dnr - as per discussion on . patient was made cmo on by the health care proxy . the patient was made comfortable with morphine, ativan and scopolamine for secretions and expired soon after extubation. medications on admission: coumadin 4mg qhs except 2mg on tues dyazide 25/37.5 qd nadolol 40mg qd neurontin 800 tid actose 45 qd kcl 20 meq qd tramadol 50 qid glyburide/metformin 2.5/500 digoxin 0.25 qd lasix 80 mg qd thyroid replacement (dose?) discharge medications: 1. levothyroxine sodium 125 mcg tablet sig: one (1) tablet po qd (once a day). 2. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po qd (once a day). 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po qd (once a day). 5. sodium chloride 0.65 % aerosol, spray sig: sprays nasal tid (3 times a day). 6. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). 7. chlorhexidine gluconate 0.12 % liquid sig: one (1) ml mucous membrane (2 times a day). 8. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po tid (3 times a day). 9. therapeutic multivitamin liquid sig: one (1) cap po qd (once a day). 10. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po qd (once a day). 11. warfarin sodium 5 mg tablet sig: tablet po hs (at bedtime): keep inr between . . 12. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 13. zinc sulfate 220 mg capsule sig: one (1) capsule po qd (once a day). 14. insulin glargine 100 unit/ml solution sig: ninety (90) units subcutaneous qam. 15. amiodarone hcl 200 mg tablet sig: one (1) tablet po qd (once a day). 16. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for fungal groin. 17. sodium chloride 0.9% flush 3 ml iv qd:prn peripheral iv - inspect site every shift 18. lorazepam 0.5-1 mg iv q6h:prn 19. fentanyl citrate 25-100 mcg iv q4h:prn 20. oxacillin sodium 10 g recon soln sig: two (2) grams injection q6h (every 6 hours) for 4 weeks. 21. ceftriaxone sodium in d5w 20 mg/ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 4 weeks. discharge disposition: extended care discharge diagnosis: cerebrovascular accident discharge condition: fair discharge instructions: please administer all medications as prescibed. followup instructions: none procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances injection or infusion of thrombolytic agent percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy excisional debridement of wound, infection, or burn transfusion of packed cells control of epistaxis by anterior nasal packing diagnoses: subendocardial infarction, initial episode of care atrial fibrillation acute and chronic respiratory failure pneumonitis due to inhalation of food or vomitus methicillin susceptible pneumonia due to staphylococcus aureus acute osteomyelitis, other specified sites epistaxis occlusion and stenosis of basilar artery with cerebral infarction 

Answer: The patient is high likely exposed to