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: nafcillin attending: chief complaint: black stools major surgical or invasive procedure: debridement of epidural abscess colonoscopy egd history of present illness: 55f who until this year had been fairly healthy but then in developed worsening lower back pain that progressed and became associated with systemic symptoms until she was found with ams and le weakness on , brought to where she was found to have mssa bacteremia with infected left hip replacement, left knee infection, psoas abscesses, epidural abscess, intradural abscess, aortic valve endocarditis with septic emboli to the brain, who underwent a prolonged hospitalization, was discharged , went to rehab, and had an episode of brbpr, for which she was sent back to . the etiology of the bacteremia is not known, though was potentially exacerbated by steroid used to treat her back pain. at the last admit, she had her knee and hip washed out, epidural abscess washed out (intradural was not as was felt the procedure was too high of a risk to cause neurologic compromise). the course was complicated by a demand myocardial infarction, felt to be due to hypotension and tachycardia of sepsis at initial presentation as well as arf (peak cr 1.9) felt to be due to nafcillin-ain versus atn; nafcillin was continued given stable cr and vast superiority of nafcillin to vancomycin in this widespread mssa infection. she was also grossly volume overloaded from fluids and blood products. anemia had been a problem during the admit, and she was noted to have brown, guaiac positive stools; her hct was 24 at discharge. gi felt scoping at last admission would've been risky, given multiple comorbidities, especially elevated tn. she was discharged to rehab on , and once there, felt to be passing tarry stools, clots, and one episode of brbpr; hct was 25, got one unit prbcs, and sent back to . she denied lh, chest pain, dyspnea, or n/v/d. in the micu, she was treated with ppi, and gi scoped pt and colonoscopy), all of which was normal. her hct has remained stable this admit without transfusion. her course has otherwise been notable for worsening renal function, the main ddx of which remains ain versus atn. past medical history: -mssa bacteremia with infection of l hip, l knee, spine, aortic valve, psoas and erector spinae muscles, and emboli to brain -htn -sciatica (was diagnosed 6-7 years ago, but pt states she has not had any back pain since then until .) -s/p left hip replacement 3 years ago. -h/o cervical cancer s/p xrt 4 years ago. -h/o barrett's esophagus in the distant past. social history: before last hospitalization she lived in with husband and daughter. denies smoking, etoh, or drugs. family history: father died at 61 with heart disease. mother is in a nursing home physical exam: t 96.5, bp 128/80, hr 88, rr 16, spo2 98%ra gen- anasarcic, lying in bed, poor function, pleasant heent- anicteric, op clear with mmm neck- no jvd, lad, thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis, + pitting edema le bilater, hands, warm/dry nails- no clubbing, + nails neuro- a&ox3, no cn deficits, good strength distally and proximally in le, sensation intact pertinent results: notable labs on transfer: wbc 7.1, hct 25.1, plt 425, mcv 89, inr 1.5; na 138, k 4.0, cl 107, bicarb 19, bun 28, cr 2.3, glc 144. . admission labs: 01:17am blood wbc-10.4 rbc-3.23* hgb-9.7* hct-27.9* mcv-87 mch-30.1 mchc-34.8 rdw-18.1* plt ct-524* 01:17am blood neuts-86.1* lymphs-8.8* monos-2.3 eos-2.4 baso-0.3 01:17am blood pt-14.3* ptt-31.7 inr(pt)-1.3* 01:17am blood fibrino-690* 01:17am blood fdp-10-40 01:17am blood glucose-112* urean-30* creat-1.9* na-140 k-3.4 cl-109* hco3-20* angap-14 01:17am blood alt-18 ast-36 ld(ldh)-386* alkphos-77 totbili-0.6 01:17am blood albumin-2.0* calcium-7.7* phos-3.6 mg-1.8 01:30am blood lactate-0.9 . discharge labs: . micro: c. difficile stool toxin negative x 1 urine culture (final ): . 10,000-100,000 organisms/ml. of two colonial morphologies. 10:00 am lumbar wound swab skin -back. gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). gram negative rod(s). rare growth. being isolated. staphylococcus, coagulase negative. rare growth. corynebacterium species (diphtheroids). sparse growth. anaerobic culture (final ): no anaerobes isolated. lumbar wound tissue (final ): citrobacter freundii complex. rare growth. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. trimethoprim/sulfa sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter freundii complex | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- <=1 s meropenem-------------<=0.25 s piperacillin---------- <=4 s tobramycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. . studies - ecg: nsr at 87, rbbb (old). no st/t changes comp to prior. . cxr: a single ap view of the chest is obtained at 15:25 hours and is compared with the prior radiograph performed . allowing for technical differences, there has been no major change. there is mild cardiomegaly with tortuosity of the aorta. there is increased opacity in the left lower hemithorax consistent with a left pleural effusion. increased retrocardiac density is seen on the left side consistent with superimposed atelectasis/airspace disease in the left lower lobe. subsegmental atelectasis is seen in the right base. there is mild pulmonary vascular prominence. a dobbhoff tube is seen in the stomach. surgical staples are seen in the upper abdomen. a left-sided picc line has its tip projected over the area of the cavoatrial junction. the previous ij line on the right side has been removed. impression: stable appearances. dobbhoff tube is in the stomach. pulmonary findings as described above. brief hospital course: 55f with recent mssa bacteremia complicated by widespread, multi-system involvement including septic emboli to brain, aortic valve endocarditis, epidural and intradural abscesses, erector spinae and psoas abscesses, artificial hip and knee infection as well as nstemi and arf who was at rehab for about a day before coming back with brbpr and worsening renal failure. . #gi-bleed -- unclear if she had a bleed or not based on history. hct was near baseline and the patient felt that she did not have a bleed. admitted to the icu where she underwent upper and lower endoscopy which were both normal. her hct's remained relatively stable throughout admission requiring 2 units prbc transfusion. she was guaiac negative and iron studies were consistent with anemia of chronic disease. she was continued on a ppi and started on epogen. consider outpatient capsule endoscopy if hct continues to trend down. . #arf -- likely ain based on urine and peripheral eosinophilia and rash. believed less likely to be atn (although there was some discussion that she became rather hypovolemic during colonoscopy prep). fena 4% supporting intrinsic renal etiology. attempted to perform gallium scan on as per the renal consultants, if positive, would support ain as a diagnosis, however patient unable to lie flat for exam and was therefore cancelled. given strong evidence of ain, her antibiotic regimen was changed from nafcillin to vancomycin by id (dosed by level with goal ~20) and remained afebrile. creatinine and rash slowly improved after d/c nafcillin. given atarax, benadryl prn for pruritis. at discharge, cre 1.8 which may represent new baseline. . #epidural/intradural abscesses -- s/p or incision and drainage of lumbar wound on by the ortho spine team at prior epidural abscess site revealed pocket of infection above the fascial plane which was washed out. drains were placed and then discontinued by the surgical team when output tapered off. wound cultures grew pan-sensitive citrobacter and the patient was changed to ciprofloxacin from aztreonam which had been started emperically after the cultures returned positive. pt is to be on cipro for at least 6 weeks per id. for her intradural abscess, during prior admission the spine team felt risk of operation too high and therefore was placed on a steroid taper that finished . followup with ortho-spine in 2 weeks for suture removal and evaluation. . #metabolic acidosis: transiently with elevated ag which rapidly closed after starting aztreonam. the patient remained afebrile with a normal lactate. also with diarrhea and renal failure contributing to low bicarbonate. . #mssa bacteremia -- was on naficillin and then changed to vancomycin per id given ain. increased vancomycin dosing to 1gm q24h as renal function improved (goal ~20; fax results to id team from rehab after discharge per discharge instructions). pt is to be on vanc indefinitely per id. . #knee and hip infection -- no evidence of recurrence. the affected hip is prosthetic and may require future replacment. the patient has followup on with dr. from orthopedics. . #psoas and erector spinae abscesses -- per id team, will need re-imaging with contrast-enhanced ct as outpatient after renal function improves. followup scheduled with dr. . . #uti -- citrobacter sensitive to fluoroquinolones, and the patient completed a course of ciprofloxacin on . repeat u/a on was positive associated with an increasing serum wbc count which then improved after restarting ciprofloxacin and replacing foley catheter. . #diarrhea/buttock skin breakdown -- c.diff negative stool samples x 3. rectal collection system in place (flexiseal) in order to protect sacral skin wounds and using special mixture of cholestyramine, lidocaine, and doubleguard (protective ointment) which should be applied to buttocks prn. stools continued to be loose. can consider removing flexiseal device when more formed. . #anasarca: likely from hypoalbuminemia and copious ivf and blood products. using ace wraps. started lasix 20mg po qd after renal function improved for diuresis with daily goal i/o -1l. . #septic brain emboli: neuro status followed as outpatient with dr. . followup appointment scheduled in 4 weeks. . #nstemi: likely was demand phenomenon during prior admission rathern than acs. no cp or other concerning symptoms at presentation. per gi team, restarted on asa. also continued metoprolol and simvastatin. . # anxiety/depression: patient distressed about diagnosis and poor prognosis. continued paxil and klonopin tid. social work followed for support. remeron started. . # hyponatremia: mild and asymptomatic. free water boluses that were being given during tube feeds were stopped and her sodium normalized. . # positive blood culture: 1/2 bottles positive for cns on . afebrile with normal wbc count. most likely a contaminant however the patient has a central line so 2 sets blood cultures drawn from peripheral and picc line on and were without growth at the time of discharge. . # access: picc (placed ). . # fen: very poor nutritional status and caloric intake only 50% of required 1500 kcal per day so restarted tfs to supplement intake. her po intake then improved and given complaints of throat soreness the tube feeds were stopped, doboff removed, and calorie counts repeated. supplements were given per nutrition consult recommendations. . # ppx: lovenox 30mg sq qd, ppi medications on admission: meds at rehab (same as on d/c): -simvastatin 80 po daily -miconazole powder prn -heparin sc tid -asa 325 daily -paroxetine 20mg po daily -lansoprazole 30mg po bid -sucralfate 1g po qid -metoprolol 100 po tid -fentanyl 25mcg/hr patch q72 hours -oxycodone 5-10mg po q4-6 prn -prednisone taper (currently on 20mg) -clonazepam 0.5mg po tid -nafcillin 2gm iv q4 -ciprofloxacin 500mg po q12 discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. aspirin 325 mg tablet : one (1) tablet po daily (daily). 3. cholestyramine-sucrose 4 g packet : one (1) packet po qid (4 times a day) as needed. 4. clonazepam 0.5 mg tablet : one (1) tablet po tid (3 times a day). 5. fentanyl 25 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 6. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 7. hydralazine 10 mg tablet : two (2) tablet po q6h (every 6 hours). 8. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 9. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed. 10. oxycodone 5 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 11. quetiapine 25 mg tablet : one (1) tablet po bid (2 times a day) as needed. 12. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical tid (3 times a day) as needed. 13. simvastatin 40 mg tablet : two (2) tablet po daily (daily). 14. ciprofloxacin 500 mg tablet : one (1) tablet po q24h (every 24 hours). 15. citalopram 20 mg tablet : one (1) tablet po daily (daily). 16. enoxaparin 30 mg/0.3 ml syringe : thirty (30) mg subcutaneous q24h (every 24 hours). 17. furosemide 20 mg tablet : one (1) tablet po daily (daily). 18. hydroxyzine hcl 25 mg tablet : one (1) tablet po qid (4 times a day). 19. phenol-phenolate sodium 1.4 % mouthwash : one (1) spray mucous membrane q4h (every 4 hours) as needed. 20. mirtazapine 15 mg tablet : one (1) tablet po hs (at bedtime). 21. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid w/meals (3 times a day with meals). 22. vancomycin 1000 mg iv q 24h 23. metoprolol tartrate 50 mg tablet : three (3) tablet po bid (2 times a day). discharge disposition: extended care facility: medical center - discharge diagnosis: primary: 1. 15mm x 4mm aortic valve vegetation - endocarditis. 2. high grade mssa bacteremia, sepsis, embolization. 3. l2-s1 epidural abscess 4. t3-l3 intradural abscess 5. right psoas, left erector spinae muscle abscesses. 6. septic arthritis - prosthetic left hip, native left knee 7. left posterior parietal, temporal, occipital embolic infarct. 8. acute interstitital nephritis and renal failure. 9. post-operative spinal incision cellulitis - citrobacter freundii. 10. gastrointestinal bleeding nos. 11. blood loss anemia. 12. non-thrombotic troponin elevation. 13. malnutrition - severe 14. volume overload - anasarca 15. citrobacter uti 16. morbilliform drug rash nos 17. partial thickness 2 x 1 cm left gluteal ulcer. secondary: 1. l1-2 moderate-to-severe spinal stenosis. 2. sciatica 3. hypertension 4. gastroesophageal reflux disease 5. left hip replacement. 6. cervical cancer s/p xrt. discharge condition: stable discharge instructions: please take all medications as prescribed. call your doctor or return to the ed immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. followup instructions: you are scheduled for the following appointments. please contact the provider with any questions or if you need to reschedule. 1. dr. from infectious diseases, on at 9am, basement, can call for directions. this is a very important appointment. orthopedics: , md phone: date/time: 11:50. you will need to have your hip and knee re-evaluated. ortho-spine: , md phone: date/time: 11:40. you will need to have your back wound evaluated and your sutures removed. id: dr. phone: date/time: 11:00 neurology: md phone: date/time: 3:30 pm you should have outpatient cardiology follow-up and cardiac stress testing. procedure: other endoscopy of small intestine enteral infusion of concentrated nutritional substances excisional debridement of wound, infection, or burn flexible sigmoidoscopy transfusion of packed cells diagnoses: acidosis unspecified pleural effusion urinary tract infection, site not specified hyposmolality and/or hyponatremia bacteremia blood in stool other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation pressure ulcer, buttock dermatitis due to drugs and medicines taken internally diarrhea subendocardial infarction, subsequent episode of care hip joint replacement other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms nutritional marasmus edema penicillins causing adverse effects in therapeutic use acute kidney failure with other specified pathological lesion in kidney infected postoperative seroma 

Answer: The patient is high likely exposed to