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: augmentin / oxycodone attending: addendum: chief complaint: following transfer to medical service: hypernatremia, delirium, dysphagia major surgical or invasive procedure: following transfer to medical service: none history of present illness: upon transfer to the medical service on : 70 yo f with history of cad, hypertension, hyperlipidemia, pvd s/p multiple amputations and vascular interventions. is now hospital day 38 following presentation for on for debridement of gangrenous l bka site. since that time has had a complicated course including performance of a left above knee amputation. at this time the patient's major outstanding issues that have prompted a transfer to the medical service are hypotension and anemia requiring recent blood transfusion, urinary tract infection, delerium, candidal esophagitis, question of recent aspiration, anemia, lack of vascular access. at time of interview the patient's main complaints are throat and mouth pain as well as the inability to eat or drink anything at this time. denies fever or chills. denies chest pain or dyspnea. review of systems: (+)ve: throat pain, dry mouth, mouth pain (-)ve: chest pain, dyspnea, leg pain, diarrhea, constipation past medical history: 1) cad s/p angioplasty ' 2) rheumatoid arthritis -on mtx/steroids 3) hx staph aureus left hand and arm and right hand and arm, and respectively. history of heel infection, . 4) hx gib ulceration 5) hypertension 6) hyperlipidemia 7) peripheral vascular disease -s/p l aka -s/p r ant tib, , sfa angioplasty -s/p l bka -s/p l second toe amputation c/b mssa bacteremia , s/p 2 wk vanco, tte neg -s/p l pta of the tibioperoneal, and sfa and stenting of the tibioperoneal bk- and ak- art for residual stenosis 8) s/p colon resection c/b cva 9) s/p lumpectomy ' 10) s/p bilateral hernia repairs ', 11) s/p bilateral cataracts ' 12) s/p left finger amputation 13) s/p appendectomy allergies: augmentin / oxycodone social history: lives with husband, two daughters one in tn, one in who is md. tobacco: denies etoh: denies family history: reviewed and noncontributory physical exam: upon transfer to medical service on : vs: t 97.0, bp 119/66, hr 90, o2sat 94% ra gen: thin and frail appearing elderly woman heent: perrl, oral mucosa strikingly dry with cracked and bleeding lips, oropharynx with dried secretions and slight erythema neck: supple, no pulm: ctab anteriorly card: rr, nl s1, nl s2, no m/r/g abd: bs+, soft, nt, nd ext: left aka with stiched surgical incision appears to be healing well with no surrounding erythema or exudates. right le with 2+ pedal edema and poor muscle tone. right upper ext with muscle wasting multiple confluent ecchymoses skin: skin is thin and fragile accross entire body neuro: oriented to person and clinical situation, not oriented to date psych: affect blunted physical exam at time of discharge: pertinent results: following transfer to medical service on : portable tte (complete) done : lvef >55%, grade i diastolic dysfunction. video oropharyngeal swallow study date of : impression: silent aspiration and ineffective clearing of residuals. us abd limit, single organ study date of : impression: 1. no ascites. 2. bilateral pleural effusions, right greater than left. 3. right likely renal cyst. video oropharyngeal swallow study date of : results: flash laryngeal penetration with thin liquid that did not result in aspiration. ct head w/ & w/o contrast study date of : conclusion: prior infarcts of the brain. air-fluid levels within the maxillary sinuses may correlate with the patient's symptoms, and suggests an acute infection. multiple extracranial calcifications, unusual in appearance and distribution. the finding could be representative of a disorder of calcium- phosphorus metabolism and less likely be post-inflammatory in nature. see above report for additional findings. ct chest, abdomen, and pelvis w/contrast study date of : impression: 1. no source of infection identified to account for neutropenic fever. 2. right lower lobe pulmonary edema. 3. moderate right and small left nonhemorrhagic pleural effusions with adjacent atelectasis. 4. liver hypodensity, likely representing a hemangioma. 5. status post colectomy. 6. bulky uterus with rounded masses arising, but also showing enhancement. findings could represent fibroid uterus; however, slightly unusual for the patient's age. also 1.3 cm left ovarian cyst is also slightly unusual for the patient's age. correlation with hormonal use is recommended, and if clinically indicated, ultrasound could be performed for further assessment after treatment of acute symptoms. bilat lower ext veins study date of : impression: bilateral lower extremity dvts. venous dup ext uni (map/dvt) right study date of : impression: cephalic vein phlebitis. no evidence of right upper extremity dvt. pelvis, non-obstetric study date of : impression: transabdominal scanning reveals a bulky fibroid uterus, with a 1.6 x 1.3 x 1.3 cm anechoic cyst located superiorly to the left of the fundus, consistent with findings on recent ct scan. this may represent a simple ovarian versus paraovarian cyst. ct head w/o contrast study date of : impression: 1. no evidence of acute extra- or intra-axial hemorrhage. 2. remote right temporal and left occipital infarcts with encephalomalacia. 3. mucosal thickening and aerosolized secretions within the maxillary and sphenoid sinuses, with similar appearance compared to prior study, which may indicate an acute inflammatory component. 4. prominence of ventricles and sulci, likely age related. selected hematology: 04:22am blood wbc-6.5 rbc-3.66* hgb-10.8* hct-32.1* mcv-88 mch-29.6 mchc-33.8 rdw-16.2* plt ct-267 05:04am blood wbc-3.4* rbc-3.08* hgb-9.0* hct-27.2* mcv-88 mch-29.3 mchc-33.2 rdw-15.5 plt ct-138* 02:47am blood wbc-0.8* rbc-2.98* hgb-8.9* hct-26.0* mcv-87 mch-30.0 mchc-34.3 rdw-15.4 plt ct-35* 04:42am blood wbc-1.8*# rbc-3.40* hgb-10.1* hct-29.4* mcv-87 mch-29.7 mchc-34.4 rdw-15.5 plt ct-24* 03:00am blood wbc-3.1* rbc-2.81* hgb-8.4* hct-24.4* mcv-87 mch-29.9 mchc-34.3 rdw-17.0* plt ct-252 05:38am blood wbc-37.1* rbc-2.71* hgb-7.8* hct-24.2* mcv-90# mch-28.9 mchc-32.2 rdw-16.4* plt ct-729* 09:00am blood wbc-16.0* rbc-3.84* hgb-11.3* hct-34.1* mcv-89 mch-29.5 mchc-33.3 rdw-18.1* plt ct-509* anc trend: 02:30am blood gran ct-240* 05:00am blood gran ct-100* 02:00am blood gran ct-* selected chemistries: 02:46am blood glucose-121* urean-46* creat-1.3* na-144 k-3.5 cl-116* hco3-20* angap-12 06:53am blood glucose-88 urean-47* creat-2.6*# na-141 k-5.5* cl-107 hco3-24 angap-16 11:53am blood glucose-115* urean-56* creat-2.6* na-142 k-4.6 cl-112* hco3-20* angap-15 04:12am blood glucose-86 urean-34* creat-1.0 na-142 k-5.3* cl-108 hco3-26 angap-13 09:00am blood glucose-124* urean-28* creat-0.7 na-141 k-3.6 cl-109* hco3-25 angap-11 02:47am blood alt-9 ast-13 ld(ldh)-142 alkphos-74 totbili-0.3 05:49am blood alt-7 ast-23 ld(ldh)-393* alkphos-135* totbili-0.2 miscellaneous: 04:23am blood caltibc-138* hapto-282* ferritn-1569* trf-106* 09:29am blood cea-4.9* ca125-69* metotrexate trend: 02:47am blood mthotrx-less than 04:42am blood mthotrx-<0.02 03:00am blood mthotrx-less than microbiology: catheter tip-iv wound culture-final (no growth) stool clostridium difficile toxin a & b test-final (negative) blood culture blood culture, routine-final (no growth) blood culture ( myco/f lytic bottle) blood/fungal culture-preliminary; blood/afb culture-preliminary (no growth) blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) urine urine culture-final (no growth) stool fecal culture, campylobacter culture, clostridium difficile toxin a & b test-final (negative) blood culture blood culture, routine-final (no growth) mrsa screen mrsa screen-final (negative) blood culture blood culture, routine-final (no growth) urine urine culture-final {yeast} blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) urine urine culture-final {enterococcus sp, vancomycin resistant} stool clostridium difficile toxin a & b test-final (negative) blood (cmv ab) cmv igg antibody, cmv igm antibody-final (negative) blood (ebv) - virus vca-igg ab-final; - virus ebna igg ab-final; - virus vca-igm ab-final (consistent with past infection) immunology (cmv) cmv viral load-final (negative) urine urine culture-final {enterococcus sp, vancomycin resistant} stool clostridium difficile toxin a & b test-final (negative) blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) urine urine culture-final {yeast, probable enterococcus} brief hospital course: hospital course starts on , following transfer of patient to internal medicine service: #. dysphagia / nutrition: upon transfer to medicine service on , patient was noted to have dysphagia, odynaphagia, hoarse voice, oral ulcers, and oral pain. her video swallowing study and speech pathology evaluation on revealed that she had silent aspiration likely due to generalized weakness and complicated by mucositis and pharyngitis. this had been presumed to be due to esophagitis and patient was being treated with nystatin. due to her dysphagia and identified aspiration risk patient was made strict npo. she was switched from oral nystatin to iv fluconazole on . over the next few days her odynaphagia improved and hoarseness resolved. patient was started on tpn on . a repeat swallowing eval on cleared her to have a dysphagia diet with aspiration precautions. patient continued on combination of full tpn with small amount of oral dysphagia diet. from through a calorie count for her oral intake was performed. patient was noted to only be consuming 60% of her recommended oral caloric intake. on her tpn was reduced to supplemental level and she was approved to start a full regular diet given that she had done well on dysphagia diet and given that part of her inadequate caloric intake could have been due to patient not having adequate choices for dietary intake. given patient's poor po intake, patient was evaluated for peg placement, but given patient's fever/bacteremia, it was decided to defer this procedure indefinitely. patient was taking regular solids with ensure supplementation on dischage. # fevers/bacteremia: on , patient was noted to be febrile. blood and urine cultures were obtained. blood cultures peripherally on (1/2 bottles) grew clostridium perfringens. blood cultures from picc and peripheral cultures thereafter were negative. urine culture by straight cath grew vancomycin resistant enterococcus, sensitive to linezolid. patient was also found to have c diff in her stool. patient was treated for these with iv flagyl, po vancomycin, and po linezolid. - continue po vancomycin/iv flagyl for 14 day course (starting ) - continue po linezolid for 7 day course (starting ) # pancytopenia attributed to methotrexate toxicity: morning after transfer to medicine service, patient noted to have decreased wbc count as well as decreased platelet count. this result was confirmed on repeat testing on evening of . methotrexate was held at this time due to concern for further toxicity to bone marrow. through use of hematology consult on , methotrexate was identified as likely primary cause of pancytopenia and leucovorin rescue was started. methotrexate level was obtained on ; however was already less than assay at this time. this indicates that the damage had likely been done following patient receiving methotrexate on and . there was no measured creatinine on those days and on , patient was discovered to have acute kidney injury. the lingering methotrexate levels due to renal failure likely first caused the mucosits and pharyngitis as above that was identified on . as methotrexate toxicity continued, pancytopenia followed the mucositis and was noted first on . as counts were trended, the patient's anc nadir was 100 on and platelet nadir was 23 on . patient received filgrastim on while patient was in the micu. patient's wbc count recovered to normal range at 4.1 on . leucovorin was discontinued on . wbc count subsequently raised to peak of 37.1 and platelets peaked at 729 on . - plan to discontinue methotrexate indefintitely #. febrile neutropenia: patient was first recognized at being neutropenic on and she spiked a fever later than day. she received full set of blood and urine cultures and a cxr was obtained. she was put on neutropenic precautions and started on cefepime. she had already been started on vancomycin on for probable vre uti. due to persistent high fevers while neutropenic, on patient was started on metronidazole and switched from vancomycin to daptomycin. on patient was still spiking fevers and thus cefepime was discontinued and meropenem as well as micafungin was added to her antimicrobial regimen. patient on became delerious in setting of her febrile neutropenia and she was transferred to the micu with a final antibiotic regimen of daptomycin, meropenem, metronidazole, fluconazole, and micafungin. patient's urine cutlure cleared on enterococcus on . in the micu, patient's neutropenia resolved on and all antibiotics were ceased. patient did not have a positive blood or urine culture from that time through to time of discharge from the hospital. in all, she never had a positive blood culture during the hospitalization. #. leukocytosis: starting on after administration of minimum allowed dose of g-csf (later realized to be approximately 2.5 times recommended dose for her body weight), patient developed a leukocytosis with peak wbc count of 37 on . from to time of discharge patient had two negative stool c. diff assays, 3 negative blood cultures, a negative urine culture, and a negative culture for central venous catheter tip. patient later () became febrile and then developed cdiff/clostridium perfringes bacteremia/vre uti, which she was treated for. wbc on discharge was 16.8. #. pulmonary embolism and dvt: on chest ct patient was incidentally noted to have bilateral pulmonary embolisms. extensive bilateral lower extremity dvts were noted on le doppers while patient in icu. likely related to prolonged hospitalization and immobility, though patient had been on appropriate prophylaxis with heparin subcutaneous. she was started on a heparin drip on with a bridge to warfarin started on . patient was started on lovenox in anticipation of discharge on . patient was re-started on coumadin on . patient had been refusing coumadin intermittantly on discharge and inr was not therapeutic. - continue lovenox 40mg , until inr therapeutic - continue coumadin 3mg daily - check inr daily #. pelvic ct scan abnormalities: ct scan with note of "bulky uterus with rounded masses arising" thought to be unusual for her age. also note of 1.3 cm left ovarian cyst inconsistent with her age. poor visualization of pelvic mass on as patient refused transvaginal ultrasound. patient had repeat ultrasound yesterday that reported bulky fibroid uterus as well as anechoic cyst consistent with simple cyst or paraovarian cyst. given this result, we are unlikely to need to pursue additional imaging as this is not consistent with malignant process; however, radiology reported that if additional imaging were to be pursued, mri would be the study of choice. #. headache: patient reporting moderate headache on and . concerning in setting of anticoagulation. no focal neuro deficits on exam and no additional confusion above baseline. head ct on was without concern for acute ich. headache was able to be controlled with tylenol #. anemia: patient's hct had slowly trended down to 20.7 on from 29.1 on . stool was guaiac negative, patient without focal pain complaints aside from head. likely all late result of methotrexate toxicity, though may consider anemia of chronic disease as possibility along with frequent phlebotomy as possibility. hemolysis labs were negative. hct has jumped from 20.7 yesterday morning to 31.9 on following transfusion of 2 units prbcs. iron studies from had low iron and low tibc with high ferritin, which was consistent with anemia of chronic disease. medications on admission: atenolol 25 folic acide 1 lasix 20 vicodin prn lisinopril 10 methotrexate 17.5 mg qweek methylprednisolone 4 omeprazole 20 opium tincture 10 mg/ml 2 drops simvastatin 20 mvi calcium 500 immodium 80 discharge medications: 1. simethicone 80 mg tablet, chewable : 0.5-1 tablet, chewable po qid (4 times a day) as needed for distension. 2. quetiapine 25 mg tablet : 0.5 tablet po qhs (once a day (at bedtime)). 3. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane tid (3 times a day). 4. metoprolol tartrate 25 mg tablet : one (1) tablet po bid (2 times a day). 5. methylprednisolone 2 mg tablet : two (2) tablet po daily (daily). 6. enoxaparin 40 mg/0.4 ml syringe : one (1) subcutaneous (2 times a day). 7. warfarin 2 mg tablet : one (1) tablet po once daily at 4 pm: please adjust dose based on inr. 8. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback : one (1) intravenous q8h (every 8 hours) for 9 days. 9. heparin flush (10 units/ml) 2 ml iv prn picc flush 10. linezolid 600 mg tablet : one (1) tablet po q12h (every 12 hours) for 1 days. 11. vancomycin 125 mg capsule : one (1) capsule po four times a day for 7 days. 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 13. ondansetron 4 mg iv q8h:prn nausea 14. citalopram 20 mg tablet : one (1) tablet po daily (daily). 15. haloperidol 0.5 mg tablet : two (2) tablet po hs (at bedtime) as needed for agitation. 16. opium tincture 10 mg/ml tincture : five (5) drop po q4h (every 4 hours) as needed for loose stool: start once patient's is finished w/ treatment for cdiff. discharge disposition: extended care facility: - discharge diagnosis: infected l bka stump sepsis hypotension non stemi chf- left ventricular systolic dysfunction, ef 30% uti bacteremia c diff colitis hypertension discharge condition: afebrile, vitals stable. discharge instructions: you were admitted to the hospital for an above the knee amputation. you had a long hospital course that was complicated. during this hospitalization you were found to have a blood clot in your legs and lungs. in addition, you were found to have a c.diff infection in your stool, a urinary tract infection, and an infection in your blood. for this, you were given antibiotics. in addition, you had difficulty with your nutrition; you were given iv nutrition for a while. you were felt to require rehab prior to returning home. if you feel like you have a fever, have chills, please follow up with the physician at the rehab center. . avoid pressure to your amputation site. followup instructions: vascular surgery please follow up with vascular surgery with dr. on at 1:45. address is , , ma. phone number is (. rheumatology please follow up with dr. in on at 2:30pm. his phone number is (; address is: ; , . please follow up with the physician at the rehabilitation center. if she decides to pursue mri for pelvic mass following her discharge, she should call dr. office for an appointment: md procedure: venous catheterization, not elsewhere classified combined right and left heart cardiac catheterization coronary arteriography using two catheters parenteral infusion of concentrated nutritional substances angiocardiography of left heart structures arteriography of femoral and other lower extremity arteries excisional debridement of wound, infection, or burn aortography repair of entropion or ectropion with wedge resection revision of amputation stump diagnoses: other primary cardiomyopathies systemic lupus erythematosus thrombocytopenia, unspecified subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery other postoperative infection urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified personal history of malignant neoplasm of breast pneumonitis due to inhalation of food or vomitus cellulitis and abscess of leg, except foot bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site intestinal infection due to clostridium difficile other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use iatrogenic pulmonary embolism and infarction pressure ulcer, lower back accidents occurring in other specified places streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] accidents occurring in residential institution atherosclerosis of native arteries of the extremities with gangrene combined systolic and diastolic heart failure, unspecified other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria infection (chronic) of amputation stump disruption of external operation (surgical) wound ulcer of other part of lower limb other specified retention of urine nutritional marasmus takotsubo syndrome necrotizing fasciitis pressure ulcer, unstageable other specified bacterial infections in conditions classified elsewhere and of unspecified site, clostridium perfringens amputation of limb(s) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation gas gangrene streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group a 

Answer: The patient is high likely exposed to