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: ceftriaxone attending: chief complaint: fever, myalgias/arthralgias, change in mental status major surgical or invasive procedure: tee colonoscopy picc placement small bowel capsule study history of present illness: mr. is a 71 y/o male with a history of insulin dependent dm2, cad s/p mi, ischemic chf (ef 20%), peripheral neuropathy, ckd stage iii-iv, depression and recent admission for multiorganism endocarditis () who presented with recurrent fevers and myalgias. he presented on with similar symptoms and was discharged on vancomycin and ceftriaxone for endocarditis. blood cultures at that time grew strep anginosus (4/4 bottles) and staph lugdinensis which were pansenstitive (see id note ). he returned on with a rash that was concerning for a drug rash; therefore, was switched to daptomycin. he completed his antibiotics on and notes doing well for a few weeks. he then began having symptoms last week with fevers up to 103. he notes associated myalgias, arthralgias, headaches and shortness of breath. he apparently also has mental status changes which improved by the time he arrived to the ed. he was initally seen at - and was given a dose of vancomycin, zofran and tylenol. he also had a chest x-ray there which was noted to be within normal limits. . in the ed his initial vitals were 99.4 91 103/54 18 96% 4l. he was started on levofloxacin 750mg iv and bactrim 3ds every 6 hours. blood cultures, u/a and head ct were done. vitals upon transfer were t99.3/hr 83, bp 110/67, rr 18, spo2 98% on ra . on the floor, he noted that he continues to feel unwell but denied any significant discomfort. he continued to have a headache and noted that he felt anxious. he denied any nausea, vomiting, rash, cough, dysuria, constipation or diarrhea. . ros: denies vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, hematuria. past medical history: mitral valve endocarditis () ischemic cardiomyopathy with an ef of 20% insulin dependent diabetes peripheral neuropathy cad status post anterior mi; s/p stent in depression h/o knee injury social history: retired; lives at home with his wife. used to own a dunkin' donuts. question of some recent cognitive decline. mr. s tobacco, alcohol, or illicit drug use. he is independent. family history: father died heart disease, mother died complications of renal failure, +dm, no colon or other malignancies in family hx. physical exam: admission exam: vs: temp 100.1, 122/71, 75 99 2l general: well-appearing man in nad, comfortable, appropriate. heent: nc/at, perrla, eomi, sclerae anicteric, mmm, op clear. neck: supple, no thyromegaly, no jvd, no carotid bruits. heart: irregular, no mrg, nl s1-s2. lungs: cta bilat, no r/rh/wh, good air movement, resp unlabored. abdomen: distended but soft/nt, no masses or hsm, no rebound/guarding. extremities: trace edema, no cyanosis or clubbing noted. skin: no rashes or lesions. lymph: no cervical lad. neuro: awake, a&ox3, cns ii-xii grossly intact, motor function grossly normal . discharge exam: afebrile, 142/71, 58, 18, 100% on ra general: well appearing man, no acute distress, sitting in bed watching tv heent: moist mucous membranes chest: cta bilaterally cardiac: irregularly irregular, no murmurs, rubs, or gallops abdomen: +bs, soft, non-tender, distended extremities: 1+ edema bilaterally (stable) neuro: alert and oriented pertinent results: admission labs: 04:16pm blood wbc-16.3* rbc-3.50* hgb-10.5* hct-31.6* mcv-90 mch-29.8 mchc-33.1 rdw-16.9* plt ct-208 04:16pm blood neuts-84* bands-10* lymphs-2* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 04:16pm blood hypochr-1+ anisocy-1+ poiklo-occasional macrocy-normal microcy-normal polychr-normal ovalocy-occasional 04:16pm blood glucose-52* urean-47* creat-1.9* na-143 k-3.7 cl-113* hco3-19* angap-15 04:14pm blood lactate-1.3 other workup 06:40am blood pt-27.7* ptt-57.2* inr(pt)-2.7* 03:50pm blood fibrino-569* 03:50pm blood fdp-10-40* 03:50pm blood d-dimer-303 08*/ 11:25am blood thrombn-91.6* 03:50pm blood alt-532* ast-641* alkphos-218* totbili-0.7 05:20am blood lipase-52 04:30am blood albumin-3.4* 05:20am blood caltibc-263 ferritn-527* trf-202 05:20am blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative 05:20am blood acetmnp-neg 05:20am blood hcv ab-negative 04:30am blood cea-4.0 psa-0.4 urine 05:14pm urine color-yellow appear-clear sp -1.011 05:14pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 05:14pm urine rbc-8* wbc-1 bacteri-few yeast-none epi-0 05:14pm urine casthy-12 urine culture (final ): no growth micro: bcx from > blood culture final 08/14/11-1501 anaerobic bottle: enterococcus faecalis aerobic bottle: no growth results called to and read-back performed by: (er) on: at:1039 by:#.jlb patient transferred to -, id fellow notified at . 1. enterococcus faecalis target route dose rx ab cost m.i.c. iq ------ ----- ------------------ ------ -- ------ --------- ------ ampicillin s <=2 ciprofloxacin s 1 levofloxacin s 1 linezolid s 2 benzylpenicilli r 16 tetracycline s <=1 vancomycin s 2 > blood culture final 08/14/11-1501 anaerobic bottle: pseudomonas aeruginosa aerobic bottle: no growth patient transferred to -, id fellow notified at . 1. pseudomonas aeruginosa target route dose rx ab cost m.i.c. iq ------ ----- ------------------ ------ -- ------ --------- ------ ceftazidime r 32 ceftriaxone r >=64 ciprofloxacin s <=0.25 gentamicin s <=1 imipenem s 2 levofloxacin s 0.5 tobramycin s <=1 bcx from - negative or ngtd cdif negative imaging/studies ecg: probable atrial fibrillation with controlled response. vertical axis. intraventricular conduction delay. st-t wave abnormalities. since the previous tracing of the axis is more right inferior. st-t wave abnormalities are less prominent. ct head w/o contrast evaluation is slightly limited given patient motion. however, no evidence of acute intracranial process. tte: ef 25-30%. compared with the prior study (images reviewed) of , the severity of mitral and aortic regurgitation have increased. estimated pulmonary artery pressures are lower (may be underestimated). overall left ventricular systolic function appears slightly less vigorous. tee: ef 30-35%. no masses or vegetations seen. moderately depressed left ventricular systolic function. compared with the prior study (images reviewed) of , the suggestion of a probable mitral valve vegetation is no longer appreciated. ct abdomen and pelvis without contrast 1. colonic pneumatosis of the cecum and right colon, which could be representative of either a vascular insult or an infectious process. 2. moderate amount of pelvic free fluid is noted. 3. colonic diverticula without evidence of diverticulitis. 4. bilateral pleural effusions. 5. gallstones without evidence of cholecystitis. ruq ultrasound: impression: 1. normal liver parenchyma. 2. cholelithiasis. 3. no ascites. kub: findings consistent with pneumatosis about the cecum and ascending colon as demonstrated on the ct scan. no findings to suggest obstruction. colonoscopy contents: there was stool within the colon that was washed away to visualize the mucosa mucosa: normal mucosa was noted throughout the colon. there was no finding to explain the cecal pneumatosis. the vascular appearance of the colon was also normal. there was no signs of ischemia or a malignancy protruding lesions medium non-bleeding external hemorrhoids were noted. excavated lesions multiple diverticula with mixed openings were seen of moderate severity in the descending and sigmoid colon and mild severity in the proximal colon impression: diverticulosis of the ascending colon, transverse colon, descending colon and sigmoid colon external hemorrhoids stool in the colon normal mucosa in the colon otherwise normal colonoscopy to cecum recommendations: further recommendations per the inpatient gi team patient should have a repeat screening colonoscopy at some point with a better preparation to rule out smaller polyps that could have been missed in the setting of a fair bowel prep. these findings do not explain the patient's recurrent bacteremia or his ct scan finding of cecal pneumatosis cxr: appropriately positioned right upper extremity picc line. mrcp without contrast: 1. stable bilateral pleural effusions. 2. trace ascites. 3. cholelithiasis without cholecystitis. 4. multiple cysts in the right kidney. ct chest 1.bilateral simple minimal pleural effusions. 2.no lung consolidation 3.pulmonary artery hypertension. 4.mild cardiomegaly with severe coronary artery atherosclerotic calcifications. 5.minimal perihepatic fluid. discharge labs: 08:28am blood wbc-8.6 rbc-3.96* hgb-11.6* hct-35.9* mcv-91 mch-29.2 mchc-32.2 rdw-18.2* plt ct-224 06:30am blood neuts-76.4* lymphs-13.7* monos-5.8 eos-3.5 baso-0.6 08:10am blood hypochr-2+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-normal ovalocy-1+ 08:28am blood plt ct-224 08:28am blood pt-18.8* ptt-38.5* inr(pt)-1.7* 11:25am blood thrombn-91.6* 08:28am blood glucose-164* urean-41* creat-1.5* na-140 k-5.0 cl-111* hco3-18* angap-16 08:28am blood calcium-8.2* phos-3.6 mg-2.3 05:20am blood caltibc-263 ferritn-527* trf-202 11:02am blood ammonia-28 05:20am blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative 04:30am blood cea-4.0 psa-0.4 05:30am blood vanco-24.0* 08:05am blood redhold-hold brief hospital course: mr. is a 71 y/o male with a history of insulin dependent dm2, cad s/p mi, ischemic chf (ef 20%), peripheral neuropathy, ckd stage iii-iv, depression and recent admission for multiorganism (staph. lugdenensis and strep anginosis )endocarditis () who presented with recurrent fevers and myalgias. . #. bacteremia: patient presented with persistent fevers and chills since completing antibiotic course. concern for treatment failure or recurrent endocarditis. blood cultures drawn at positive for enterococcus and pseudomonas. he was initially started on levofloxacin and bactrim. this was changed to vancomycin and meropenem for broader coverage. tte and tee negative for vegetations. ct abdomen w/o contrast concerning for pneumatosis of cecum, but surgery recommended no intervention at this time. id following closely, and recommended continuing current antibiotic regimen (vanc and meropenem) for 3 weeks through . patient had no adverse reaction to the vancomycin, which was a concern on last admission. he had some diarrhea with the antibiotics, but was c.diff negative. wbc and lactate all trending down. gi consulted and recommended colonoscopy to evaluate for colonic source of bacteremia. the patient was transferred to the icu overnight for closer monitoring while taking the moviprep given concern for perforation, but he did fine. after the colonoscopy he was transferred back to the general medical floor. the colonoscopy was normal: no evidence of ulceration or ischemia. an mrcp was done, which did not show evidence of billiary source for bacteremia. ct chest was negative for infectious process. in order to evaluate small bowel process, small bowel capsule study was pursued. the results are pending and will be communicated to patient while he as at rehab. basically: pseudomonas and enterococcus bacteremia, no obvious source but likely gi tract. patient will complete a total 3-week course of vancomycin and meropenem. . #. transaminitis: presented with elevated lfts with normal bili. tried to discontinue all possible offenders including tylenol, statin, depakote. also recently discontinued flagyl. hepatology consulted. concern for possible microabscesses. mrcp was performed. both mrcp and ct abdomen showed gallstones but no evidence of obstruction and tbili normal. hepatitis panel negative. iron studies not concerning for hemochromatosis. has not been hypotensive throughout hospital course making shock liver unlikely. most likely cause is pyogenous spread from blood to liver. resolving with antibiotics. statin will need to be restarted as outpatient once lfts normalize. . # hyperkalemia: he intermittently had elevated k in low 5s which responded to fluid and kayexalate. likely seconday to poor renal function. potassium was normalized and low-dose lisinopril was started. if potassium continues to be high, lisinopril can be discontinued. . # coagulopathy: patient was noted to have elevated coags. concern was for liver disease vs dic vs medication (pradaxa) vs antibodies or factor defficiency. all dic labs were within normal limits. thrombin time elevated, likely as a result of the pradaxa. a mixing study was inconclusive. the patient was given 1 unit of ffp and vitamin k in the icu however, coags remained elevated. after transferring back to the floor (1 week after admission), coags began to trend down. . # systolic chf: started on metoprolol, lisinopril, and asa. statin was held in setting of elevated liver enzymes. lasix dose was changed from 80mg qd to 40mg qd. . # dm2: initially was started on home regimen however became hypoglycemic requiring d50 and d5 in his fluids. lantus was held and then restarted at a small dose. patient is now receiving lantus 5unit with an insulin sliding scale. the insulin can be uptitrated as needed. . # cad: patient denied any chest pain and ekg had no chages compared to old ekg. he was started on toprol 25mg xl, lisinopril 2.5mg qd, and aspirin 81mg qd. isosorbide 20mg tid was continued. . # atrial fibrillation: chads of 3 (chf, htn, dm). was recently started on pradaxa by pcp. was held given his coagulopathy and elevated creatinine. mr. was started on coumadin for his afib on discharge. he will need to have close inr monitoring and titration of coumadin for a goal inr of . . # hematuria: patient had blood in his urine twice during admission. this will need to be evaluated further by your pcp and possibly urologist. . # code status: on this admission, patient stated he was dnr/dni, which he had discussed with his wife and his lawyer. contact: home, , cell , son: . transitional issues: 1. management of coumadin/inr 2. iv antibiotics for a total of 3 weeks through 3. follow-up of small bowel capsule study 4. hematuria (further work-up needed) 5. hyperkalemia: currently stable, but will need to be monitored (may need to d/c lisinopril) 6. trend lfts 7. restart statin 8. neuro-psych evaluation medications on admission: 1. lantus 100 unit/ml solution sig: see instructions subcutaneous twice a day: 5 units in the morning and 40 units in the evening. 2. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 3. venlafaxine 150 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po once a day. 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. isosorbide dinitrate 20 mg tablet sig: one (1) tablet po tid (3 times a day). 6. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical twice a day: apply to affected area until rash improves. do not apply to face. disp:*60 grams* refills:*4* 7. lasix 80 mg tablet sig: one (1) tablet po once a day. 8. diphenhydramine hcl 12.5 mg tablet, chewable sig: one (1) tablet, chewable po every four (4) hours as needed for itching: sedating medication. do not drive or participate in other hazardous activities while on this medication. disp:*30 tablet, chewable(s)* refills:*0* 9. pradaxa (unknown dosage) 10. glyburide 10mg in the morning 5mg in the evening discharge medications: 1. lantus 100 unit/ml solution sig: five (5) units subcutaneous twice a day: this can be uptitrated at rehab if your sugars continue to be elevated. 2. humalog 100 unit/ml solution sig: one (1) unit subcutaneous at bedtime: as per insulin sliding scale. 3. venlafaxine 75 mg capsule, ext release 24 hr sig: two (2) capsule, ext release 24 hr po daily (daily). 4. isosorbide dinitrate 20 mg tablet sig: one (1) tablet po tid (3 times a day). 5. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day). 6. furosemide 20 mg tablet sig: two (2) tablet po daily (daily). 7. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q8h (every 8 hours): please take 500mg intravenously through . 8. vancomycin 500 mg recon soln sig: 2.5 recon solns intravenous q 24h (every 24 hours): please infuse 1250mg iv every 24 hours through . 9. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm: as directed by your physician at rehab or a coumadin clinic. 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. toprol xl 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 12. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for upset stomach. 13. outpatient lab work please check cbc with diff, chem 10, liver function tests, and vancomycin level on and . please fax these results to the infectious disease clinic at: . 14. lorazepam 1 mg tablet sig: one (1) tablet po at bedtime as needed for anxiety: please hold for oversedation. 15. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: multi-organism bacteremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you on this admission. you came to the hospital because you were having fevers and chills. blood cultures showed that you had bacteria in your blood stream. we treated you with strong antibiotics that will end on 8/30th. we put in a picc line, so that you could get these antibiotics more easily. . we suspected that the bacteria was coming from your gastrointestinal tract. we did a trans-esophageal echo, which did not show endocarditis. we did a colonoscopy that was normal. we did an mri of your liver and biliary system, which also did not show a cause of your bacteremia. we are currently doing a small bowel capsule study, to evaluate the integrity of your small intestine. these results will be available after you are discharged. you will get a call from the gastroenterologists next week with the results. . we started a medication called coumadin for your atrial fibrillation. you will have to have frequent blood tests to monitor this medication. . please make the following changes to your medications: 1. start taking vancomycin 2. start taking meropenem 3. start taking coumadin (your inr will need to be checked at rehab, and your coumadin dose adjusted accordingly) 4. start taking toprol 25mg xl once a day 5. start taking lisinopril 2.5mg once a day 6. stop taking depakote 7. stop taking atorvastatin (this is a medication for high cholesterol, and it will need to be restarted by your primary care physician as soon as your liver tests normalize. this can be done in the next 2-3 weeks). 8. stop taking tylenol until your liver enzymes normalize 9. stop taking lorazepam 1mg three times a day; you can take 1 mg of lorazepam once a night as needed for anxiety 10. stop taking glyburide 11. we changed your insulin (lantus) to 5units in the morning and 5 units in the evening because your sugar was low. this medication can be uptitrated at rehab if your sugars are high 12. stop taking dabigatran 13. stop taking lasix 80mg once a day, and start taking lasix 40mg once a day unless directed otherwise by your doctor. 14. start taking aspirin 81mg once a day for your heart . you will need to continue antibiotics through . you will need to follow-up with your primary care physician, infectious disease doctors, and the liver specialists. followup instructions: please contact your primary care doctor once you are discharged from rehab to schedule an appointment. . department: infectious disease when: tuesday at 10:30 am with: , md building: lm bldg () campus: west best parking: garage please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. . . department: liver center when: wednesday at 11:20 am with: , md building: lm campus: west best parking: garage md procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart colonoscopy diagnoses: hyperpotassemia coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute kidney failure, unspecified chronic kidney disease, stage iv (severe) atrial fibrillation personal history of other infectious and parasitic diseases diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes depressive disorder, not elsewhere classified other specified forms of chronic ischemic heart disease long-term (current) use of insulin old myocardial infarction other encephalopathy streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] headache do not resuscitate status dehydration streptococcal septicemia acute on chronic systolic heart failure other and unspecified coagulation defects hematuria, unspecified other abnormal blood chemistry diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled diverticulosis of colon (without mention of hemorrhage) external hemorrhoids without mention of complication nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] septicemia due to pseudomonas unspecified vascular insufficiency of intestine other specified disorders of intestine 

Answer: The patient is high likely exposed to