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: zoloft attending: chief complaint: hypotension major surgical or invasive procedure: intubation/extubation bronchoscopy picc placement history of present illness: ms. is a year old woman with history of coronary artery disease presented on with anorexia, emesis x 2, right-sided abdominal pain, malaise, and fatigue. she was noted to have a mildly elevated white count of 13.6k. she had a ruq ultrasound in the ed which demonstrated moderate amount of sludge with few shadowing stones in the gall bladder. a presumptive diagnosis of acute cholecystitis was made, and she was admitted to the surgical service. she was started on ciprofloxacin and metronidazole. she was seen by gi (dr. during the admission, who recommended conservative management and consideration of elective cholecystectomy as an outpatient. her blood pressures on ranged 110-147/53-82, and on ranged 132-180/73-91. she had increased ruq pain the morning of , and then triggered the night of for tachycardia to the 140's and hypoxia to 80% on room air. cardiac enzymes were checked, and the first set was elevated (troponin 0.11, ck at that time 82). second set was elevated as well (t 0.22, ck 103). cardiology was consulted. of note, she was consented for laparascopic cholecystectomy this morning. the morning of admission, she again triggered for hypotension (80/46), heart rate 56. she was given her usual dose of metoprolol (12.5mg) this morning. on arrival to the , she is confused, tachypneic, and pale appearing. no further review of systems was obtained from the patient. per the family, she had been complaining of back pain she had been admitted twice within the past year for choledocholithiasis ( with two 8-10mm stones in cbd, sphincterotomy/stent but no stone extractions; stone extraction and stent removed). past medical history: - hypercholesterolemia - coronary artery disease - asthma - osteoarthritis social history: no tobacco, etoh. daughter is , has two other daughters. family history: non-contributory physical exam: discharge pe general appearance: no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: endotracheal tube lymphatic: cervical wnl cardiovascular: rrr, no murmers appreciated resp: ctab abdominal: soft, non-tender, bowel sounds present skin: stage 1 decubitis ulcer neurologic: not oriented to city, place, month; sleepy but arousable and conversant, responds to questions pertinent results: admission labs: 05:20pm wbc-13.8*# rbc-4.33 hgb-13.1 hct-38.2 mcv-88 mch-30.3 mchc-34.4 rdw-13.3 05:20pm neuts-87.7* lymphs-7.6* monos-4.0 eos-0.5 basos-0.1 05:20pm alt(sgpt)-17 ast(sgot)-31 alk phos-97 tot bili-1.4 05:20pm glucose-133* urea n-23* creat-1.0 sodium-141 potassium-4.5 chloride-102 total co2-27 anion gap-17 discharge labs: wbc-8.8 rbc-3.05* hgb-9.2* hct-29.1* mcv-96 mch-30.2 mchc-31.7 rdw-13.9 plt ct-249 glucose-89 urean-20 creat-1.1 na-141 k-4.1 cl-107 hco3-27 angap-11 ct abdomen : 1. evidence of acute cholecystitis, with progression of inflammation since . there is increased distention, wall thickening and stranding, and at least one intraluminal stone is seen. no intra- or extra-hepatic biliary ductal dilatation. 2. an intraluminal oval rounded hypodense structure is seen near the junction of the second and third portions of the duodenum, previously hyperdense on a contrast-enhanced study (and therefore possibly enhancing). the structure appears quite hyperdense on the prior exam of . the etiology is unclear. there is no upstream duodenal dilation to suggest obstruction. the differential diagnosis includes atypical food particles/debris (if not truly enhancing), polyp (if enhancing) and neuroendocrine tumor is not excluded. 3. small bilateral pleural effusions and associated atelectasis. 4. circumscribed fluid attenuation structure in the right hilar region as described, likely representing a pericardial cyst. tte : the left atrium is dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with moderate to severe hypokinesis of the mid to distal inferior wall, inferolateral wall and apex. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: moderate regional left ventricular systolic dysfunction. diastolic dysfunction. mild aortic and moderate mitral regurgitation. moderate pulmonary artery systolic hypertension. a pericardial cyst is not seen on this study. microbiology 9:35 pm blood culture blood culture, routine (final ): streptococcus anginosus (milleri) group. final sensitivities. sensitivity testing performed by sensititre. clindamycin <=0.12 mcg/ml. gram positive rods. unable to further identify. sensitivities: mic expressed in mcg/ml _________________________________________________________ streptococcus anginosus (milleri) group | clindamycin----------- s erythromycin----------<=0.25 s penicillin g---------- 0.06 s vancomycin------------ <=1 s aerobic bottle gram stain (final ): gram positive cocci in chains. reported by phone to dr @ 3:00 pm. anaerobic bottle gram stain (final ): reported by phone to dr. @ , . gram positive rod(s) consistent with corynebacterium and propionibacterium species. and blood cultures: no growth to date brief hospital course: yf with significant cardiac history admitted with ? cholecystitis, transferred to for hypotension, hypoxia, elevated white count. #) cholecystitis: ms. has a history of choledocholothiasis, and she had 2 ercp procedures in with no complications. she presented on with symptoms of anorexia, vomiting, r-sided abdominal pain, and ct scan and u/s reports concerning for acute cholecystitis. she was admitted to surgery, started on cipro/flagyl, and monitored with serial exams as her functional status and comorbidities did not make her a good candidate for surgery. in the setting of her sepsis (see below), surgery continued to opt for medical management and her coverage was broadened to include vancomycin and zosyn (started ). vancomycin was discontinued when the bacteremia pathogen was identified (strep milleri). over the course of her hospitalization, ms. improved clinically with her abdominal pain resolving and improving lfts. she was discharged with instructions to continue broad coverage for gi pathogens with zosyn for 2 weeks, followed by a course of penicillin g (renally dosed). #) sepsis: ms. was triggered on for increasing temperature to 99.5, tachycardic to 140s, and increased o2 requirement, as well as hypotenstion., she was found to be bacteremic with positive cultures growing gram positive strep milleri. she had a ct torso to evaluate for source of infection, which showed worsening cholecystitis. her urine was clear at that time. she was intubated and stabilized in the icu, and was transferred to the floor with all blood cultures from being negative at time of discharge. ms. also underwent an echocardiogram to evaluate for endocarditis in the setting of bactermia. she was found to have a thickend mitral valve leaflet. it was decided that she would not be a good candidate for further imaging with trans-esophageal echocardiogram, so she will be treated for a 6-week course of antibiotics for presumed endocarditis based on tte. #) respiratory failure: ms. required intubation secondary to respiratoy failure in the setting of sepsis and nstemi. she had a clear x-ray. she was gently diuresed, fio2 and peep were downtitrated, she was given albuterol/ipratropium mdis for history of asthma. she was easily extubated and rapidly weaned down to minimal oxygen. since being on the floor, she has remained >95% on 2l nasal cannula and continues to breath comfortably. #) nstemi: ms. suffered nstemi while septic secondary to increased demand. troponin peaked at .91, ck at 211. echo showed moderate regional left ventricular systolic dysfunction, diastolic dysfunction, mild aortic and moderate mitral regurgitation. moderate pulmonary artery systolic hypertension. cardiology evaluated her and recommended 3 days of heparin gtt (). she was continued on statin, asa, and b blocker with no plans for catheterization. given her depressed ef, acei was recommended once her bp was able to tolerate an additional antihypertensive. she was discharged with plans to add ace-inhibitor when she can tolerate and to increase statin to goal of 80mg as tolerated. #) anuria/acute renal failure: creatinine peaked at 1.8 in the setting of sepsis/hypovolemia. her creatinine improved with fluid resuscitation and treatment of infection to 1.1 at time of discharge. #) back pain: while on the floor, ms. reported back pain but was unable to localize location, did not have point tenderness, and no neurologic deficits. this was most likely musculoskeletal, so we treated with lidocaine patch and standing tylenol. the posibility of epidural abscess from bacterial seeding was discussed, but unlikely given exam findings. mri should be considered for further evaluation if she has hemodynamic decline or develops neurologic deficits. her current planned treatment with 6 weeks of targeted antibiotics would be appropriate for discitis/osteomyelitis as well. furthermore, she is a poor surgical candidate and we would likely be managed conservatively. we were also concerned that this pain was recurring in the setting of cholecystitis, but we were treating with antibiotics and already determined that she was a poor candidate for surgical intervention. this new pain regimen was initiated on so it will be important to monitor for effectiveness on discharge. she was discharged to rehab center in . medications on admission: medications on transfer from icu: - heparin 5000 units sc tid - hydrocodone-acetaminophen tab po q6h:prn - acetaminophen 1000mg po q6h:prn - metoprolol tartrate 12.5 mg po bid - albuterol inhaler puff ih q4h:prn sob/cough/wheeze - metronidazole (flagyl) 500 mg iv q8h - aspirin 81 mg po daily - morphine sulfate 1 mg iv q2h:prn breakthrough pain - atorvastatin 10 mg po daily - omeprazole 20 mg po daily - citalopram hydrobromide 20 mg po daily - ciprofloxacin 200 mg iv q12h - donepezil 5 mg po hs - docusate sodium 100 mg po bid - trazodone 50 mg po hs - fluticasone-salmeterol diskus (100/50) 1 inh ih discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po at bedtime. 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: inhalation twice a day as needed for shortness of breath or wheezing. 3. citalopram 20 mg tablet sig: one (1) tablet po once a day. 4. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q8h (every 8 hours) for 8 days: end date . 8. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 9. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed for itching. 10. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qday (). 12. docusate sodium 50 mg/5 ml liquid sig: po bid (2 times a day). 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 15. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation twice a day. 16. penicillin g pot in dextrose 2,000,000 unit/50 ml piggyback sig: one (1) intravenous every four (4) hours for 4 weeks: first dose after finishing zosyn, last dose . 17. morphine 15 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain: breakthrough pain only, hold for sedation, rr<10 or confusion. discharge disposition: extended care facility: - discharge diagnosis: 1. cholecystitis secondary diagnosis 2. nstemi 3. sepsis/strep milleri bacteremia 4. acute renal failure discharge condition: stable, breathing comfortably on 2l/nc, sleepy but arousable and conversant discharge instructions: you were admitted to the hospital for cholecystitis (infection of the gall bladder), and this was complicated by a blood infection. likely because of this infection, you had low blood pressures and difficulty breathing. you required intubation in the icu, but you recovered with antibiotics, you were extubated, and you were transferred to the floor. because of your extensive infection, you were too ill to have surgery to remove your gall bladder. you may consider discussing this surgery with a surgeon when you are well and off antibiotics. also because of your infection and low blood pressues, you experienced a small heart attack while you were in the hospital. we also saw evidence of possible infection in your heart valves. this was probably from the infection in your blood. because of the infection of your valves, you will need antibiotic treatment for 6 weeks. please take all medications as prescribed. the following changes were made to your medication regimen: 1) we started you on antibiotics. please take zosyn iv as prescribed until wednesday . after that, please take penicillin as prescribed for 4 weeks. 2) we discontinued your trazadone because you were very sleepy. 3) we started tylenol and lidocaine patch for your pain. 4) we discontinued your lasix because your blood pressure was low. if you develop worsening shortness of breath, difficlty breathing, low blood pressures with systolic <90, fevers >101 degrees, or any other concerning symptoms, please seek medical attention immediately. followup instructions: please follow-up with your primary care doctor, dr. , 1 week after being discharged from rehab. you can call to schedule an appointment. please keep the following scheduled appointment: provider: , dermatology gen- (nhb) date/time: 2:15 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube arterial catheterization diagnoses: subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute kidney failure, unspecified severe sepsis acute respiratory failure septic shock hypovolemia streptococcal septicemia acute on chronic systolic heart failure calculus of gallbladder with acute cholecystitis, without mention of obstruction endocarditis, valve unspecified, unspecified cause 

Answer: The patient is high likely exposed to