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 77 year old female, who presented with six to seven weeks of severe right knee pain and warmth. she notes chills, no fevers or rigors. in recent days prior to admission, she had noted increased chills. she has noted decreased ambulation secondary to pain. te patient was seen by the orthopedic service , and a knee x-ray was taken, which was within normal limits. a repeat x-ray was taken , with a small effusion noted. laboratories were drawn at that time with blood cultures, the blood cultures grew gram positive cocci in pairs and chains, in two separate bottles. the patient's white blood cell count was 16.8 and her esr was 96. she was told to come to the emergency department. in the emergency department, the orthopedic service saw the patient and tapped her knee. in the emergency department, the patient received oxacillin, levofloxacin and vancomycin. of note, the patient had developed a heart rate to the 140s, noted to be atrial flutter. she received cardizem 5 mg intravenously with a decrease in her heart rate to the 70s and a decrease in her systolic blood pressure to 62. the patient received normal saline boluses and a dopamine drip was initiated. upon initiation of dopamine drip, she returned into atrial fibrillation with a rapid ventricular response to the 170s. the dopamine drip was discontinued and her blood pressure correspondingly fell to 69 systolic. at that point, neo-synephrine drip was started, which she tolerated well. she was transferred to the medical intensive care unit at that time. medical intensive care unit course: in the medical intensive care unit, the patient was maintained on oxacillin and levofloxacin which was eventually changed to vancomycin and levofloxacin. she continued to receive normal saline boluses and neo-synephrine for blood pressure which was subsequently weaned in several days after admission. the patient continued to have episodes of atrial flutter requiring diltiazem boluses intravenously as needed, however, she had a tendency to drop her blood pressure with this medication. after successfully weaning the neo-synephrine, the patient had another episode of hypotension requiring reinitiation of neo-synephrine. on , the patient spiked a temperature to 102 degrees fahrenheit and was pancultured. at that time, the patient also experienced oxygen desaturation. a chest x-ray was performed which was consistent with congestive heart failure. her maintenance fluids were discontinued. while in the medical intensive care unit, a transthoracic echocardiogram demonstrated no vegetation of the valves, and left ventricular ejection fraction of greater than 65%, mild to moderate aortic regurgitation and moderate mitral regurgitation. the patient's theophylline was discontinued secondary to her continued episodes of atrial fibrillation/atrial flutter and this medication's likely erythrogenic potential. on , the patient had two more episodes of supraventricular tachycardia of which she was asymptomatic with no decrease in her blood pressure. a transesophageal echocardiogram was eventually performed to rule out valvular endocarditis which was significant for a vegetation demonstrated of her native aortic valve. on , the patient was transferred to the medical floor and upon arrival was found to be in atrial fibrillation with a rapid ventricular response to the 140s. she denied chest pain, shortness of breath, nausea, vomiting, diaphoresis, abdominal pain, radiating pains or light-headedness upon arrival. physical examination on transfer: vital signs revealed temperature 100.8, blood pressure 148/70, heart rate 130, oxygen saturation 98% on two liters. in general, an elderly female in no acute distress. head, eyes, ears, nose and throat examination is normocephalic and atraumatic. sclera anicteric. mucous membranes are moist. the oropharynx is clear. neck - no jugular venous distention appreciated. chest is clear anteriorly. cardiovascular - irregular, tachycardic, normal s1 and s2, ii/vi systolic ejection murmur appreciated at the right upper sternal border. no rubs appreciated. abdomen is soft, nontender, nondistended, normoactive bowel sounds. extremities - no edema, 2+ dorsalis pedis and posterior tibial pulses. the right knee was without erythema but was noted to be warmer than the left knee. laboratory data on transfer: white blood cell count 12.5, hematocrit 28.0, platelet count 232,000. sodium 141, potassium 3.6, chloride 107, bicarbonate 26, blood urea nitrogen 8, creatinine 0.7, glucose 104. calcium 7.7, magnesium 1.7, phosphorus 2.1. tsh is 3.2. vancomycin 15.7. right knee, three views, plain films obtained , which demonstrated small joint effusion, no fracture was identified. a portable chest x-ray on , demonstrated no radiographic evidence of acute pulmonary or cardiac disease processes. a chest x-ray on , demonstrated small pleural effusions bilaterally, unchanged from the prior radiograph. there were two calcified granulomas noted within the left lung. ct angiogram on , was preliminarily negative for pulmonary embolus. there were noted to be atelectatic changes in the bases of the lungs bilaterally. the pleural effusions noted on chest x-ray were also evident. microbiology - joint fluid from , demonstrated 2+ polymorphonuclear leukocytes, no microorganisms seen on gram stain. the fluid culture resulted in no growth. the joint fluid analysis demonstrated 5,480 white blood cells, 945 red blood cells, 94 polys, 4 lymphocytes, 2 monocytes and no joint crystals. two separate blood cultures from , demonstrated nutritionally variant streptococcus sensitive to clindamycin, gentamicin, penicillin and vancomycin. urine culture on , and , were negative for growth. two blood cultures drawn on , were negative for growth. two blood cultures on , were negative for growth. electrocardiogram on , demonstrated recurrent supraventricular tachycardia with a rapid rate of 171. slight st segment depression leads v3 through v4, raising the possibility of rate related ischemia. electrocardiogram performed on , demonstrated atrial fibrillation with a rapid ventricular response with occasional ventricular premature beats. delayed r wave transition was noted. compared to the previous electrocardiogram on , this atrial fibrillation was new. transthoracic echocardiogram on , demonstrated left ventricular ejection fraction of 55%, mild aortic regurgitation, moderate mitral regurgitation, trivial tricuspid regurgitation, and physiologic pulmonic regurgitation. there were no valvular vegetations demonstrated. a transesophageal echocardiogram on , demonstrated a left ventricular systolic function which was normal, left ventricular ejection fraction greater than 55%. aortic valve demonstrated a moderate size vegetation. no valve abscess was seen. moderate aortic regurgitation was demonstrated. the aortic valve vegetation was 0.6 by 1.0 centimeters in size. this was on the noncoronary cusp of the aortic valve. electrocardiogram performed on , demonstrated normal sinus rhythm with occasional premature ventricular contractions. occasional ventricular premature beats were noted. there was low limb lead voltage. delayed r wave transition. the premature ventricular contractions were new compared to the prior tracing. past medical history: 1. chronic lymphocytic leukemia. 2. chronic obstructive pulmonary disease. 3. status post right total knee replacement , secondary to osteoarthritis. 4. hypertension. 5. peptic ulcer disease in . 6. bladder polyp excision. 7. coronary artery disease. allergies: no known drug allergies. medications on transfer: 1. vancomycin one gram intravenous q12hours. 2. levofloxacin 500 mg p.o. q24hours. 3. mirtazapine 15 mg p.o. q.h.s. 4. ipratropium bromide four puffs four times a day. 5. salmeterol two puffs twice a day. 6. fluticasone propionate 110 mcg two puffs twice a day. 7. tylenol p.r.n. 8. ativan p.r.n. 9. maalox p.r.n. 10. heparin 5000 units subcutaneous q12hours. 11. protonix 40 mg p.o. q24hours. 12. albuterol/atrovent nebulizers q6hours p.r.n. social history: the patient lives with her husband in . she is a past smoker, quit five years ago. she has a fifty pack year history of tobacco usage. she denies alcohol usage. impression: the patient is a 77 year old female with strept variant bacteremia, endocarditis involving aortic valve, infectious source likely the right knee, who was transferred from the medical intensive care unit after requiring short term use of pressors secondary to hypotension. hypotension was likely secondary to sepsis. her medical intensive care unit course was complicated by episodes of supraventricular tachycardia requiring intravenous diltiazem. the patient arrived to the medical floor once again in this abnormal rhythm. the patient was transferred to the medical floor for continued intravenous antibiotic administration, treatment of her arrhythmia, and transition to an acute care rehabilitation facility. hospital course: 1. cardiovascular - the patient was noted to be hypotensive on admission and was transferred to the medical intensive care unit with pressors. she required pressors for several days, but was quickly weaned off this medication. her initial blood pressure support medication was dopamine, however, her rhythm did not tolerate this as she went into supraventricular tachycardia. the dopamine was discontinued and she was initiated on neo-synephrine which she tolerated very well. upon arrival to the medical floor, the patient's blood pressure remained stable between 110 to 140 systolic. the patient was noted to be in atrial fibrillation with a rapid ventricular response in the medical intensive care unit as well as on the medical floor. she required multiple infusions of diltiazem to control her rate. in the intensive care unit, she required diltiazem to be administered on three separate occasions. when she arrived to the medical floor in atrial fibrillation with rapid ventricular response, 25 mg of intravenous diltiazem was required to convert the patient into normal sinus rhythm. her blood pressure tolerated this medication well, she had lowest systolic blood pressure of 100 during this episode. diltiazem oral preparation was initiated in low doses. the patient remained on telemetry which demonstrated several more episodes of this supraventricular tachycardia. the diltiazem was titrated up to the dose she will be receiving upon discharge, 60 mg p.o. four times a day. telemetry demonstrated that she tolerated this dose well with no episodes of atrial fibrillation. the patient continued to maintain normotensive blood pressure. the patient was initially on an ace inhibitor on admission, however this medication had been held secondary to her low blood pressure. captopril was initiated on , and will continue to be titrated up as tolerated. 2. infectious disease - the patient was originally referred to the emergency department for blood cultures positive for gram positive cocci in pairs and chains. blood cultures were obtained in the emergency department on , which demonstrated streptococcus-nutritional variant, sensitivities as above. in the emergency department, the patient was started on oxacillin and levofloxacin as well as vancomycin. this was changed to vancomycin and levofloxacin in the intensive care unit. upon arrival to the medical floor, the patient was started on gentamicin and levofloxacin was discontinued at that time. upon return of the sensitivities for this organism, vancomycin was changed to penicillin. an infectious disease consultation was obtained and this service felt that the likely source for this organism was the right prosthetic knee joint. orthopedics was reconsulted to assess whether or not a repeat tap of this knee would be indicated. the orthopedic service felt that the original knee tap was not indicative of the knee as the source of infection, however, they did recommend a longer course of antibiotics given the concern for the prosthetic joint. penicillin and gentamicin were continued on the medical floor with a goal gentamicin dosing and interval for synergism (trough goal less than 1.0, peak between 2.0 to 3.0). the patient remained afebrile from , through the time of dictation. the patient will require intravenous antibiotics for a total of six weeks of gentamicin, last dose to be administered . the patient's last dose of penicillin will be administered on . she will require follow-up in the infectious disease clinic in four weeks upon discharge. she will need to schedule an appointment with dr. , telephone . while on gentamicin, she will require peak and trough levels until the goals are met and q.monday, wednesday, friday creatinine determinations. after the dose is stabilized, the gentamicin trough should be obtained two times per week. while on the penicillin, the patient will need weekly complete blood count and liver function tests. two sets of blood cultures will be required two weeks after completing the antibiotics and the patient's knee will need to be reevaluated at that point. if effusion is present, the knee may need to be tapped. a repeat echocardiogram should be considered to check for valvular vegetations at this time as well. 3. pulmonary - the patient has a history of chronic obstructive pulmonary disease. she has been maintained on metered dose inhalers including atrovent and serevent as well as pulmicort. the patient also on -dur prior to admission. her inhalers were continued throughout the admission, however, the -dur was discontinued secondary to its erythrogenic potential. upon discussion with the patient, it had been suggested to her in the past that she use home oxygen, however, records were not available to corroborate this. while admitted, she has required supplemental oxygen to maintain her oxygen saturations greater than 93%. prior to discharge, her oxygen requirements had slightly increased from three liters per nasal cannula to four liters nasal cannula. there were two episodes where the patient became acutely short of breath. these occurred on , and . with each occurrence, she felt prompt relief after using her atrovent and albuterol mdi. a chest x-ray was obtained on , which was not significant for congestive heart failure or infiltrates. she received albuterol/atrovent nebulizers during these episodes with a good effect. considering her chest x-ray and clinical examination is somewhat consistent with chronic obstructive pulmonary disease or congestive heart failure as the etiology for the increasing oxygen requirement, a ct angiogram of the chest was obtained on . preliminary report from this study resulted in no evidence of pulmonary thrombi. bilateral basilar atelectatic changes were demonstrated although small pleural effusion was also noted. the patient's hypoxia may be related to her chronic obstructive pulmonary disease and will require continued maintenance and rescue inhalers, nebulizers as needed. the patient's cardiopulmonary status will need continual assessment at the rehabilitation facility. there should be a low threshold for obtaining a repeat echocardiogram if she becomes short of breath and a chest x-ray is consistent with congestive heart failure to rule out valvular dysfunction. 4. hematologic - the patient's hematocrit was 29.8 on admission. it is unclear why she had anemia as her baseline hematocrit was 41.9 on . her hematocrit remained stable, however, during admission with the lowest value of 26.0 on . she received one unit of packed red blood cells with an appropriate increase in her hematocrit to 30.0. she was heme negative from the stool during this admission. hemolysis laboratories were negative. while on penicillin, the patient should have weekly complete blood count as noted above. secondary to the patient's history of coronary artery disease, the threshold for transfusion is hematocrit of less than 28.0. discharge diagnoses: 1. sepsis-streptococcus nutritional variant. 2. atrial fibrillation. 3. hypotension, requiring pressors in the intensive care unit. . endocarditis-aortic valve native. 5. chronic obstructive pulmonary disease. 6. anemia. 7. right knee prosthesis. medications on discharge: 1. mirtazapine 15 mg p.o. q.h.s. 2. atrovent four puffs four times a day. 3. salmeterol two puffs twice a day. 4. fluticasone propionate 110 mcg two puffs twice a day. 5. tylenol 325 to 650 mg p.o. q4-6hours p.r.n. 6. maalox 15 to 30 ml p.o. four times a day p.r.n. 7. protonix 40 mg p.o. q24hours. 8. albuterol nebulizer solution q6hours p.r.n. 9. ipratropium bromide nebulizer q6hours p.r.n. 10. heparin 5000 units subcutaneous q8hours. 11. captopril 6.25 mg p.o. three times a day, hold for systolic blood pressure less than 100. 12. diltiazem 60 mg p.o. four times a day, hold for heart rate less than 65 and systolic blood pressure less than 105. 13. penicillin g potassium 3 million units intravenously q4hours, last dose . 14. gentamicin 60 mg intravenously q12hours, last dose . condition on discharge: stable. discharge status: the patient is being discharged to acute care rehabilitation facility for further management. discharge instructions: 1. the patient will require q.monday, wednesday, friday creatinine levels and gentamicin peak/trough levels. 2. the patient will also require weekly complete blood count and liver function tests while on penicillin. 3. the patient will also require two sets of blood cultures to be obtained two weeks after completing her antibiotics. 4. she will need an evaluation of her right knee at that time to determine persistent effusions and a repeat tap of that knee will be decided at that time. 5. she will also require a repeat echocardiogram after the antibiotics have completed to check for persistent valvular vegetation and valvular dysfunction. physician : the patient will need to be followed up in four weeks with dr. , . the patient is to call to schedule an appointment. the patient should also schedule an appointment to be seen with her primary care physician within one to two weeks upon discharge to the rehabilitation facility. , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart other esophagoscopy arthrocentesis diagnoses: congestive heart failure, unspecified unspecified essential hypertension chronic airway obstruction, not elsewhere classified atrial fibrillation atrial flutter other specified cardiac dysrhythmias acute and subacute bacterial endocarditis streptococcal septicemia chronic lymphoid leukemia, without mention of having achieved remission 

Answer: The patient is high likely exposed to