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: patient recorded as having no known allergies to drugs attending: chief complaint: weakness and tremulousness major surgical or invasive procedure: 1. ngt 2. radiolabelled wbc scan history of present illness: 52 yr old female with hx of alcohol abuse presented to with severe weakness on night of . per sister, she called her friend to take her to the hospital and he called the police who came and took her to . at , she was found to have markedly elevated lfts (ast >> alt), alcohol level of 46, anion gap acidosis (ph 7.29, gap 26) and transferred to for further management. at , pt also received levaquin/flagyl (given that source of acidosis not know), banana bag and amp of d50 for hypoglycemia. on arrival to , pt found to have tylenol level of 58.4 and was given nac x 2 iv along with ativan for etoh withdrawal. pt reported to dr. feeling more depressed over past 2 weeks on learning that she is being evicted from her apartment. her alcohol intake has increased due to her depression to a quart to a pint of vodka/wine per day and she reports her last drink being a bottle of wine at 8 am . she denies suicidal ideations, stating that she has a 23-yr old son who means a lot to her and that she would accomplish that through other means if she wanted to. she does admit to recent dui. she denies tylenol overdose; she has taken between extra strength tylenol a day for the past 3 weeks for knee and ? back pains. pt has aches and pains due to running. she denies any other medication other than herbal supplements. pt states that on the day of presentation to osh, pt had severe weakness (unclear whether due to tremulousness or weakness) and could not walk so she called her landlord to take her to the hospital. pt complains of neck and back pain, mild abd pain, nausea. + emesis x 1 prior to coming to osh. no hx of dysuria, fevers, chills, hematemsis, melena, brbpr. . pt was monitored in from until w/diazepam for ciwa>10. was tachycardic to the 120-130s, without seizures. her hco3 was repleted. due to acute withdrawal symptoms, she required sedation. she received nac q 4 hours (3500mg). developed fulminant hepatic failure with markedly increased coagulopathy (ptt to 66.6, inr = 26.1, alt = on ; ast = 7621 on ). mental status trended down with confusion, hallucinations, garbled nonsensical speech, and lethargy. she became agitated and disoriented, requiring restraints to prevent her from removing her lines. gradually lfts and coagulation markers began to improve, although pt remained obtunded and difficult to arouse. despite concerns regarding her ability to protect her airway, intubation was ultimately not required as she became less obtunded by . spiking fever on was evaluated by abd ct which showed an inflamed head of the pancreas, dx as acute pancreatitis. tube feeds were held and a -gastric tube was passed post pyloric. on , the patient's blood cultures were positive for gram negative rods and the patient was started on vancomycin, iv bid. following mental status improvements, she developed tremendous back pain, which was treated with morphine prn. on , was transferred from to the medicine floor medically stable but still w/continued occasional hallucinations, and has fluctuating mental status. her lfts were trending downwards at the time, with alt = 387, ast = 115. past medical history: 1. alcohol abuse, hx of blackouts and alcohol withdrawal seizures 2. left arm fracture 3. s/p ilial tibial band release x 2 4. c-section 5. raynaud's syndrome 6. depression 7. chronic joint and low back pain attributed to running social history: the patient is divorced, with a 23 year-old son who she does not have much contact with at this time. she has two older sisters who have been very involved in her care. . the patient has a long history of alcohol abuse, and the family has made multiple interventions to get her help. she has had a recent dui. she reports that she had a 6 year period of sobriety through in pt treatment, aa, and counseling, following being physically assaulted. however she relapsed last fall, following quitting her job at the country club where she had been doing seasonal work, following a disagreement with her manager. since then, she has drank all day, every day, to a total of approximately 1 pint ?????? 1 qt daily of vodka/wine since . the patient has a history of multiple admissions to different hospitals for alcohol-related injuries, although she has never been intubated. she has a history of alcohol-related blackouts and withdrawal seizures. history of dts is unknown. she reports that her alcohol intake has increased with her depression, which was exacerbated by her recent dui as well as eviction from her apartment. when she was sober, she described herself as an athlete, enjoying running, biking, and climbing. her last drink was a bottle of wine, on the day of admission. family history: + alcohol abuse in both parents father died from thyroid cancer at age 27 physical exam: temp 100 (ed) 97.4 (), bp 121/69, hr 97, rr 16, o2 100% ra gen: tremulous, nad, ao x 3 heent: perrl, eomi, mmm neck: no neck tenderness or neck stiffness, supple cv: regular, tachy, diastolic murmur heard at rusb chest: clear except for min crackles at right base abd: + hyperactive bowel sounds; soft, mildly distented; tender to palpation in ruq, esp medially; palpable liver edge 1-2 cm below costal margin : no edema, old ecchymoses on left foot; 2+dp; + sl asterixis; no palmar erythema neuro: cn 2-12 intact; 5/5 strength in upper ; 5/5 strength in distal lower but 3/5 strength on bilateral hip extension; sensation intact; 2+ dtrs all pertinent results: osh labs: ** chem ** na: 128 k: 3.3 cl: 88 hco3 14 bun/cr: 5/0.6 glucsoe 63 ca: 8.7 alb: 4.2 tp: 7.0 t bili: 1.6 alt: 290 ast 1031 alk phos: 112 etoh: 46 ck: 49 144 lipase 117 bhcg: neg . ** cbc ** wbc: 6.6 hct: 36.1 mcv: 97.1 plt: 643 . ** abg ** 7.295/22.6/70 . ** coags ** inr 1.1 ptt 29.5 . labs at see below, but notable for: inr 1.4 (rising)--> 3.6 tylenol level 59 ast 938 down--> 1789 alt 295 stable--> 60 t bili 1.7 (sl up)--> 2.3 alk phos 81 (down) lactate 4.4 . repeat abg 7.42/27/113 11:57pm glucose-128* urea n-7 creat-0.5 sodium-132* potassium-3.4 chloride-102 total co2-13* anion gap-20 11:57pm alt(sgpt)-1459* ast(sgot)-4967* ld(ldh)-4152* tot bili-3.0* 11:57pm calcium-8.4 phosphate-1.3* magnesium-1.7 11:57pm vit b12-> folate->20.0 11:57pm ammonia-41 11:57pm acetmnphn-neg 11:57pm wbc-8.3 rbc-3.50* hgb-11.9* hct-34.4* mcv-98 mch-34.1* mchc-34.7 rdw-14.0 11:57pm plt count-423 11:57pm pt-35.5* ptt-38.3* inr(pt)-8.3 09:31pm lactate-2.3* 09:15pm glucose-177* urea n-6 creat-0.4 sodium-134 potassium-3.6 chloride-102 total co2-15* anion gap-21* 09:15pm alt(sgpt)-1001* ast(sgot)-3370* ld(ldh)-2780* alk phos-79 amylase-705* tot bili-2.1* 09:15pm lipase-46 09:15pm calcium-8.0* phosphate-1.1* magnesium-1.7 09:15pm acetmnphn-5.1 09:15pm pt-30.1* ptt-36.9* inr(pt)-6.0 04:00pm glucose-131* urea n-6 creat-0.5 sodium-134 potassium-3.8 chloride-102 total co2-15* anion gap-21* 04:00pm alt(sgpt)-613* ast(sgot)-1789* ld(ldh)-1638* alk phos-81 amylase-1106* tot bili-2.3* 04:00pm lipase-49 04:00pm iron-183* 04:00pm caltibc-187* ferritin-> trf-144* 04:00pm hbsag-negative hbs ab-negative hbc ab-negative hav ab-negative 04:00pm acetmnphn-12.1 04:00pm hcv ab-negative 04:00pm wbc-5.9 rbc-3.51* hgb-11.5* hct-34.3* mcv-98 mch-32.8* mchc-33.5 rdw-13.6 04:00pm plt count-481* 04:00pm pt-23.4* ptt-33.7 inr(pt)-3.6 04:00pm ret aut-1.2 12:56pm lactate-4.4* 12:41pm glucose-140* urea n-6 creat-0.6 sodium-132* potassium-4.0 chloride-100 total co2-18* anion gap-18 12:41pm calcium-8.4 phosphate-1.3* magnesium-2.0 09:26am type-art o2-100 po2-113* pco2-27* ph-7.42 total co2-18* base xs--4 aado2-591 req o2-95 intubated-not intuba 09:26am lactate-5.5* 08:53am comments-green top 08:53am lactate-5.7* 05:40am glucose-157* urea n-6 creat-0.6 sodium-128* potassium-4.3 chloride-95* total co2-16* anion gap-21 05:40am alt(sgpt)-295* ast(sgot)-938* alk phos-81 tot bili-1.7* 05:40am albumin-4.0 calcium-7.9* phosphate-2.8 magnesium-2.0 05:40am acetone-negative osmolal-271* 05:40am asa-neg ethanol-neg acetmnphn-58.4* bnzodzpn-neg barbitrt-neg tricyclic-neg 05:40am wbc-5.9 rbc-3.31* hgb-11.0* hct-32.4* mcv-98 mch-33.1* mchc-33.9 rdw-13.8 05:40am neuts-94* bands-0 lymphs-5* monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 05:40am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-1+ microcyt-normal polychrom-occasional 05:40am plt smr-unable to plt count-535* 05:20am urine hours-random 05:40am pt-14.8* ptt-28.5 inr(pt)-1.4 05:20am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 05:20am urine color-yellow appear-clear sp -1.016 05:20am urine blood-neg nitrite-pos protein-neg glucose-tr ketone-50 bilirubin-neg urobilngn-neg ph-5.0 -neg 05:20am urine rbc-0 wbc-0-2 bacteria-many yeast-none epi-<1 cr was stable in low 0.3 to 0.4 range, began to increase on , peaking at 1.0 on and returned down to 0.7 on and was stable until discharge. alt and ast on admission were 295 and 938 respectively, peaked on at and 7621, and returned to within normal limits by . amylase and lipase: amylase peaked at 1106 at the time of admission and then trended down. lipase peaked at 641 on then trended downward. iron studies: iron-183* caltibc-187* ferritin-> trf-144* (no evidence iron deficiency) hct ranged high 20s-low 30s throughout. . imaging : abd ultrasound: 1. normal appearance of the liver. 2. normal liver doppler. 3. possible gallbladder polyps versus circumferential fold adjacent to the gallbladder neck. cxr:no acute cardiopulmonary disease ct abd and pelvis: 1. unremarkable appearance of the small and large bowel, without mural thickening, overt mucosal enhancement (in the non-opacified bowel), or evidence of obstruction. 2. diffusely hypodense and enlarged appearance of the liver, consistent with hepatitis, fatty infiltration, and/or liver failure in this clinical setting. 3. iud in place, with fibroid uterus. small amount of pelvic free fluid may be physiologic in patient of menstural age. ct head without iv contrast: no evidence of intracranial hemorrhage or edema. cxr: new airspace opacity within the left lower lobe and small left effusion, suggestive of possible aspiration/pneumonia. ct abd and pelvis: 1. diffuse fatty infiltration of the liver and heterogeneous enhancement suggestive of underlying acute hepatitis. 2. new moderate amount of intraabdominal ascites and bilateral small pleural effusions with associated dependent atelectasis. 3. new focal edema within the head and uncinate process of the pancreas, consistent with focal pancreatitis. 4. jejuno-jejunal intussception of proximal small bowel loops seen in the left mid quadrant, not seen previously. no definite lead point lesion discerned. no evidence for obstruction or other bowel wall pathology identified. spine mr: findings indicative of discitis and osteomyelitis at l3-4 level with mild epidural soft tissue changes. no evidence of fluid collection to indicate an abscess. no evidence of high-grade spinal stenosis. head ct: no ct evidence of brain abscess. ct abd: no intrabdominal or pelvic abscesses are identified. no findings to indicate septic emboli. specifically, there is uniform enhancement in the spleen, kidneys and liver. mri c-spine: findings of concern for osteomyelitis involving c5 and c6, with prevertebral soft tissue swelling gadolinium enhanced cervical and thoracic spine mri: no definite thoracic spine pathology. no abscesses. cxr: pa and lateral chest compared to chest radiographs since , most recently : atelectasis and pleural effusions have cleared. lungs are fully expanded. heart is normal size. there is no evidence of central adenopathy. abdominal u/s: no ascites, no acute cholescystitis mri of l-spine: findings are suggestive of discitis and osteomyelitis at l3-4 level with slight involvement of the paraspinal soft tissues by phlegmon with possible extension to the right anterior epidural space as indicated on the previous examination. there is no significant interval change seen involving the degree of discitis. slight loss of disc height is identified at l3-4 due to evolution of the discitis process. further followup is suggested within 4-6 weeks with gadolinium administration. left le u/s with doppler: negative left lower extremity dvt study ct of abd and pelvis: unremarkable ct of the abdomen and pelvis. no change compared to the prior study. head ct: no evidence of acute intracranial hemorrhage or mass effect and no ct evidence of brain edema. wbc scan study: photopenic foci in the lower lumbar spine (l3-4), and possibly in the mid-lower cervical spine corresponding with the patient's suspected diskitis/osteomyelitis by mri. no other foci of abnormal tracer uptake to suggest other sites of infection. picc placement: tip of the right picc line overlies the cavoatrial junction. there is no pneumothorax. > > > > > > >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> micro : urine culture: gram positive bacteria. 10,000-100,000 organisms/ml. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. : urine culture: clear: no bacterial growth : blood culture: coagulase negative staph from aerobic bottle. no anaerobic growth. staphylococcus, coagulase negative. final sensitivities. clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ 2 s : blood cultures positive for coag neg staph : surveillance blood cultures negative: no growth in aerobic or anaerobic bottles : picc line tip culture: no significant growth. brief hospital course: 52f with hx of etoh abuse who initially presented to osh with weakness sent to and found to have elevated tylenol level, and liver failure that developed into fulminant hepatic failure in the micu. course c/b pancreatitis, high-grade bacteremia, and then found to have c3-4, l4-5 osteomyelitis sensitive to vancomycin. . # acute alcoholic hepatitis/ fulminant liver failure: due to the patient's chronic alcohol abuse, she could have had some degree of chronic liver failure, although prior lab studies were not available for comparison. the combination of increased alcohol use and daily tylenol (2-3g for 3 weeks pta), however, would likely be enough insult to cause acute hepatic toxicity from elevated tylenol levels/decreased clearance of tylenol. tylenol level on admission to was 59 and trended down. rising inr (1.4 on admission, eventually peaking at 26.1 on hd 3), was concerning for developing hepatic failure, especially as liver dysfunction can be delayed by 3-5 days from insult. albumin was preserved at 4.0 indicating that intrinsic liver function was still intact. ast>>alt was consistent with alcoholic hepatitis pattern. ast peaked at 7621 and alt at , after which both trended down to the normal range over several weeks. discriminant function was 14.5--> increased to 48.3. meld score was 36 on admission (scale 0-40) indicating severe, fulminant hepatic failure. hepatitis serologies were negative. the patient was judged to be a poor transplant candidate based on her current alcohol abuse and multiple attempts at sobriety with relapse. . n-acetylcysteine was loaded and then continued at 70mg/kg q4h (with compazine to prevent nausea). vitamin k was administered to correct coagulopathy. lactulose was started on hd 3 with concern for hepatic encephalopathy. her mental status had trended down with confusion, hallucinations, garbled nonsensical speech, and lethargy developing. she became agitated and disoriented, requiring restraints to prevent her from removing her lines. although gradually lfts and coagulation markers began to improve, pt remained obtunded and difficult to arouse. despite concerns regarding her ability to protect her airway, intubation was ultimately not required as she became less obtunded by . waxing and mental status, believed to be at least partially due to hepatic encephalopathy, persisted over the next few weeks. fevers and continued pain (see below) likely also contributed. treatment with lactulose was continued throughout the hospital course, with eventual clearing of mental status by the week prior to discharge. . pt was monitored in from until w/diazepam for ciwa>10. was tachycardic to the 120-130s, without seizures. her hco3 was repleted. due to acute withdrawal symptoms, she required sedation. spiking fever on was evaluated by abd ct which showed an inflamed head of the pancreas, dx as acute pancreatitis, for which she received vancomycin, iv bid. following mental status improvements, she developed tremendous back pain, which was treated with morphine prn. on , was transferred from to the medicine floor medically stable but still w/continued occasional hallucinations, and has fluctuating mental status. her lfts are trending downwards, at alt = 387, ast = 115. . # coag-negative staph bacteremia: patient began spiking fevers in the icu and work up eventually revealed high grade coag-negative staph bacteremia (oxacillin resistant but vanco-sensitive) from blood cultures from (initially continued to grow positive despite antibiotics). unclear initial source. patient was started on vancomycin (), & dose was adjusted to target serum levels. patient reported upper and back pain (worse than her baseline lower back pain) and mri eventually showed osteomyelitis in 2 areas of the spine (c-spine and l-spine). neurosurg recommended a hard neck collar x 8 weeks. the patient was fitted then refitted for a hard collar but could not tolerate them. after long discussion of the risks of not wearing a hard neck collar, the patient decided against wearing one due to discomfort. patient was also fitted with a back brace, which she wore with some relief of her lower back pain. transthoracic echocardiogram () and transesophageal echo () showed no evidence of endocarditis. neurosurgery was consulted but no surgery was planned as there was no fluid collection. patient had several days of occasional spiking fevers from and therefore a wbc scan was performed, which revealed uptake consistent with known osteomyelitis but no other areas of abnormal uptake. surveillance blood cultures did not grow bacteria and the patient's fevers resolved for >1 week prior to discharge. plan to follow-up with clinic and reimaging to determine course of vancomycin. final blood culture on was pending at the time of discharge but had no growth to date. . # depression: pt with very depressed affect after prolonged icu stay but mood improved somewhat during remainder of hospital stay. pt denies si but has admitted to worsening depression since losing her job and being evicted from her home. . # alcohol abuse: long history of etoh abuse but had been sober for ~6 years but recently relapsed after an argument at work a few weeks prior to admission. upon admission, pt initially had anion gap acidosis, +urinary ketones, likely in aka/starvation ketoacidosis. last drink at 8 am. displayed signs of alcohol withdrawal including visual hallucinations, tachycardia, intermittent hypertension and agitation in the icu. pt was managed conservatively with valium based on ciwa scale. pt rec'd 1 week of iv thiamine (then switched to po) as well as folate and mvi supplements. social work and addiction medicine followed patient throughout hospital stay. will need continued outpatient follow-up for this, including aa and psych follow-up. . # lower back pain: chronic & likely from muscle spasm (tight muscles noted on exam). avoided starting muscle relaxants in case they altered mental status and patient was started on narcotics for pain, which she tolerated well. at time of discharge, patient's lbp was well-controlled on morphine sulfate long-acting 30 mg q12h standing dose with morphine sulfate immediate release 15-30 mg po q 4-6h prn. back brace in place as above for comfort. . # anemia: pt with macrocytic anemia most likely alcohol abuse. given hx, pt felt to be at risk of gi bleed but no sx to indicate active bleeding. iron studies were checked which showed fe (183), ferritin (>), and trf (144) so no evidence fe def anemia. b12 (>) and folate (>20). patient did receive 2u prbc on , which she tolerated well. hct was otherwise stable in the high-20, low-30s range. . # uti: pt with ua + nit, many bacteria but no pyuria/hematuria/, send urine cx. ua consistent with gram negative urinary tract infection. treated with levaquin x 3 days, finished on . . # anion gap acidosis: pt with mixed metabolic acidosis. anion gap acidosis likely secondary to both alcoholic ketoacidosis and lactic acidosis from hepatic failure. no osmolar gap. pt's delta/delta gap of indicative of either chronic resp alkalosis or non-gap acidosis superimposed on anion gap acidosis. observed pco2 lower than expected co2 so likely an underlying resp alkalosis, acute liver failure. lactate high liver necrosis, no evidence of mesenteric ischemia on cta of abdomen. patient had high rr to compensate for acidosis. acidosis slowly resolved in the icu and her acid-base status was stable by the time of transfer to the regular medicine floor. . # pancreatitis: patient complained of abdominal pain in icu and amylase was found to be very elevated. lipase was normal (49) but given her synptoms, this was concerning for pancreatitis. patient received aggressive ivf and her abdominal pain resolved and amylase normalized (1106--> 155). . # fen: patient was on tube feeds via ngtube in the icu but tolerated pos very well after extubation. . # ppx: patient was maintained on ppi for gi prophylaxis, pneumoboots for dvt prophylaxis (while bedbound in icu). . # code: full . # communication: sister, , identified as health care proxy. she gave permission for us to speak with and is aware she is here. pt also has 23-yr old son who lives in . medications on admission: tylenol xs 2 tablets 2-3 times daily for past 3 weeks; previously on ibuprofen. later admitted to taking tylenol and acetominophen alternately but both in same day. apparently she did not know they were the same medication? herbal supplements including filaria root for anxiety and melatonin for sleep discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed. 2. multivitamin capsule sig: one (1) cap po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. morphine 15 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 6. quetiapine fumarate 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: adhesive patch, medicateds topical patches on for 12 hours off for 12 hours () as needed for back pain. 8. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed). 9. vancomycin 500 mg recon soln sig: seven y (750) mg intravenous q 12h (every 12 hours): tentative end of course is (8 weeks total). definite end date to be determined by infectous disease follow-up. 10. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 11. lactulose 10 g/15 ml solution sig: thirty (30) ml po qid (4 times a day) as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: osteomyelitis, lumbar and cervical spine fulminant hepatitis from acetaminophen and alcohol use coagulase-negative staphlococcus bacteremia depression pancreatitis anemia, likely related to past alcohol use lower back pain, chronic discharge condition: stable, ambulating, tolerating pos discharge instructions: contact md if you develop fever/chills, shortness of breath, worsening back pain, or other concerning symptoms please take all medications as directed. you will be getting vancomycin (an intravenous antibiotic) for a total of 8 weeks. you have received about 4 weeks so far. the tentative end date is . the exact course of treatment will be determined on follow-up with your infectious disease doctor. please avoid tylenol and any products containing tylenol or acetaminophen. followup instructions: -provider: . tan where: lm disease phone: date/time: 9:30 primary care visit: -provider: , md where: phone: date/time: 1:30 please continue to attend aa meetings as you usually do. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances transfusion of packed cells removal of intrauterine contraceptive device diagnoses: urinary tract infection, site not specified acute and subacute necrosis of liver alcoholic cirrhosis of liver acute kidney failure, unspecified acquired coagulation factor deficiency severe sepsis unspecified osteomyelitis, other specified sites depressive disorder, not elsewhere classified hepatic encephalopathy poisoning by aromatic analgesics, not elsewhere classified acute pancreatitis unspecified deficiency anemia alcohol withdrawal acute alcoholic intoxication in alcoholism, continuous other staphylococcal septicemia accidental poisoning by aromatic analgesics, not elsewhere classified 

Answer: The patient is high likely exposed to