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: aicd firing major surgical or invasive procedure: - intubation x 2 - transesophageal echo - arterial line insertion - right ij central line insertion - aspiration of multiple joints (both knees, right wrist, both olecranon bursae), multiple times - arthrotomy right wrist with washout and debridement. - bilateral knee arthrotomies with anterior synovectomies. - excision right knee prepatellar gout tophi. history of present illness: mr. is a 78 year old male transfered from with a history of cad and chf who presents with aicd firing, palpitations, and newly diagnosed colon cancer. he had been in a nursing home and reported fevers and chills at his nursing home for 1-2 days prior to presentation. on the morning of admission his icd fired several times and so he came to the ed. vs in ed were t103.8, o2 sat 89%ra , hr 128, bp 121/39. he was given vanco/ctx/azith/zosyn at ed for pneumonia. he was reportedly extremly dry on exam. he was given 4l of iv fluids for tachycardia. sinus tachycardia evolved into a. fib with rvr and the patient received diltiazem 10mg iv x2. given concern for pe patient he was transferred to for a v/q scan. in the ed at initial vs were: t97.4, hr 120 bp 124/58, rr 24, o2 sat 89% ra, 4l nc was in mid-90's. exam was notable for bilateral le edema and guaiac positive stool. the patient had several episodes of a. fib with rvr and was given bolus iv diltiazem and started on a diltiazem gtt. v/q scan was done prior to arrival on the floor. on the floor, the patient complained of total body joint pain involving elbows, knees, ankles, and lower left leg. he denied chest pain, shortness of breath, or other complaints. prior to arrival on the floor he had received 5l ns. the patient and family report that patient was diagnosed with colon cancer (no known mets) 3 weeks ago. has recently been treated for a pneumonia/copd exacerbation as an outpatient and had been with increasing oxygen requirements. most recently he was at house (rehab/nursing home). review of sytems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied myalgias. past medical history: - coronary artery disease, status post coronary artery bypass grafting times two. - s/p aicd placement, - chf (ef 40-50%), moderate to severe mr, mild-to-moderate ar - copd/emphysema, fev1 0.72 at 28%, fvc 1.32 at 40% - colon cancer, newly diagnosed in setting of gi bleed, from 6 cm above the anus about 12 cm in the sigmoid, a large adenocarcinoma of the rectosigmoid which was sent to biopsy. biopsy reports adenocarcinoma, moderately differentiated and invasive. - skin ca. - gerd - gout - htn - hypercholesterolemia - deviated septum. psh: cabg x2 , aicd placement, r ankle pinning 25 years ago social history: married with one child. retired salesman. he does not drink alcohol. exercises by walking on a treadmill. no known drug allergies. family history: non-contributory physical exam: vital signs: t 100.3, hr 109, bp 119/51, r 20, 96% on 2l nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: wbc-10.3 rbc-3.96* hgb-8.9* hct-29.3* mcv-74*# mch-22.6*# mchc-30.5* rdw-19.0* plt ct-158 neuts-93.5* lymphs-4.4* monos-1.9* eos-0.1 baso-0.1 pt-13.4 ptt-36.0* inr(pt)-1.1 esr-104* glucose-236* urean-60* creat-1.7* na-133 k-4.8 cl-103 hco3-20* ck(cpk)-34* calcium-7.6* phos-4.2 mg-2.0 uricacd-9.1* tsh-0.73 crp-greater than 300 lactate-2.2* urine color-yellow appear-hazy sp -1.019 urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-1 ph-5.0 leuks-neg urine rbc-* wbc- bacteri-few yeast-none epi-0-2 transe-0-2 urine amorphx-mod joint fluid aspirations: wbc-* rbc-8500* polys-98* lymphs-0 monos-0 macro-2 crystal-mod shape-needle locatio-i/e birefri-neg comment-c/w monoso wbc-* rbc-* polys-94* lymphs-2 monos-4 crystal-mod shape-needle locatio-i/e birefri-neg comment-c/w monoso micriobiology: 3:10 pm blood culture #2. **final report ** blood culture, routine (final ): staph aureus coag +. final sensitivities. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s aerobic bottle gram stain (final ): reported by phone to @ 1:43a . gram positive cocci. in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. 10:53 am joint fluid source: kneeleft. **final report ** gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. reported by phone to 1410 . fluid culture (final ): staph aureus coag +. moderate growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s 12:05 pm joint fluid source: right wrist. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and chains. reported by phone to 1653 . fluid culture (final ): staph aureus coag +. moderate growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. gram stain reviewed: gram positive cocci in clusters were seen (). sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s 3:41 am sputum source: expectorated. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): budding yeast. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): sparse growth oropharyngeal flora. enterobacter cloacae. moderate 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. staph aureus coag +. moderate growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | staph aureus coag + | | cefepime-------------- 2 s ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin---------<=0.25 s clindamycin----------- <=0.25 s erythromycin---------- <=0.25 s gentamicin------------ <=1 s <=0.5 s levofloxacin---------- <=0.12 s meropenem-------------<=0.25 s oxacillin------------- 0.5 s piperacillin---------- =>128 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s <=0.5 s 8:46 pm stool consistency: soft source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 3:13 am blood culture source: line-a-line. **final report ** blood culture, routine (final ): bacteroides fragilis group. beta lactamase positive. anaerobic bottle gram stain (final ): gram negative rod(s). 8:59 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast. respiratory culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. oropharyngeal flora absent. yeast. sparse growth. staph aureus coag +. sparse growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. gram negative rod(s). rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s 12:24 pm sputum site: endotracheal source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast. respiratory culture (preliminary): sparse growth oropharyngeal flora. 12:24 pm stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). blood cultures from , , , all no growth imaging studies: ecg - atrial fibrillation with a rapid ventricular response. non-specific st-t wave changes. there are non-diagnostic q waves in the inferior leads. compared to the previous tracing atrial fibrillation is new. v/q scan - impression: low likelihood ratio for pe. cxr ap - impression: relatively stable x-ray examination given differences in depth of inspiration and technique. no acute pulmonary process. transthoracic echo - the left atrium is moderately dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. there is moderate regional left ventricular systolic dysfunction with severe inferior, inferolateral and lateral hypokinesis. the remaining segments contract normally (lvef = 30-35%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. an eccentric, posteriorly-directed jet of moderate (2+) mitral regurgitation is seen ( 0.2 cm2, regurgitant volume 26 ml/beat). the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is no pericardial effusion. impression: no vegetations seen. moderate regional left ventricular systolic dysfunction, c/w cad. mild aortic regurgitation. moderate mitral regurgitation. compared with the report of the prior study (images unavailable for review) of , left ventricular systolic function has deteriorated. mitral and aortic regurgitation severity has increased. cxr pa & lat - findings: in comparison with the earlier study of this date, there is little interval change. the lateral view is suboptimal and adds little to the characterization of the left basilar opacification, which most likely represents atelectasis. transesophageal echo - no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. overall left ventricular systolic function is moderately depressed (lvef= 35-40 %). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. impression: no echocardiographic evidence of left atrial thrombus or valvular vegetations. moderate mitral regurgitation is present. renal ultrasound - impression: 1. moderate right hydronephrosis. 2. gallstones and sludge without evidence of cholecystitis. 3. son sign was negative. renal scan - impression: severe impaired bilateral renal function. ruq ultrasound - impression: moderately distended gallbladder with cholelithiasis, not significantly changed, but with no specific features for cholecystitis. ct abdomen/pelvis, non-contrast - impression: 1. no evidence of hydronephrosis. large right parapelvic cyst unchanged. 2. interval worsening of now consolidation at the lung bases bilaterally, which may represent aspiration, pneumonia or combination of both. bilateral small effusions. 3. cholelithiasis. distention of the gallbladder appears to have slightly increased, which may be related to patient's fasting state. 4. bilateral renal cysts, not fully evaluated given lack of iv contrast. 5. previously seen rectosigmoid mass not well appreciated on this non- contrast study. persistent rectosigmoid fat stranding. picc line placement - addendum: on review of this study in conjunction with the frontal and lateral chest radiographs, the right picc is identified terminating in the lower svc or cavo-atrial junction. kub - impression: no evidence of obstruction. no abdominal free air. brief hospital course: mr. is a 78 year old male with cad, chf, and recently diagnosed colon cancer who presented with aicd firing in the setting of new onset atrial fibrillation with rvr and mssa bacteremia and septic arthritis. # sepsis, bacteremia, hypotension: the patient had high grade bacteremia, with blood cultures from turning positive approximately 12 hours after admission to , eventually yielding mssa. admission blood cultures from as well as multiple joint aspirations all grew out mssa. given his pain on presentation and multiple positive joint aspirations he was felt to have metastatic septic arthritis. the source for initial bacteremia was not clear and transesophageal echo showed no evidence of endocarditis. per recommendations from the infectious disease team, the patient was empirically treated with nafcillin for 6 days and then switched to a combined regimen of ciprofloxacin, cefepime, and flagyl starting the evening of when his surveillance blood culture from the day prior grew gram negative rods in the anerobic culture bottle (eventually grew b. fragilis). the patient had previously been noted to have gram negative rods in his sputum (enterobacter cloacae), however, he had no clear evidence of pneumonia by chest x-ray. the patient also required aggressive iv fluid resuscitation on presentation to support his blood pressure and intermittantly required pressors as well. # atrial fibrillation: the patient initially presented with a. fib with rvr ?????? apparently a new diagnosis for this patient. his aicd had fired four times prior to admission for heart rates > 180. he was ruled out for an mi with serial cardiac enzymes. the day following admission the electrophysiology consultants performed a tee that showed no clot in in the heart and no evidence of valvular or pacemaker lead endocarditis. the patient was started on amiodarone and metoprolol and cardioversion was planned as it was felt that he was likely not a candidate for coumadin given his recent gi bleed and colon cancer. however, he spontaneously developed bradycardia at a v-paced rate of 50 bpm post-tee in the setting of hyperkalemia. he then spontaneously converted to nsr after correction with d50, sodium bicarbonate and insulin. metoprolol was discontinued due to hypotension and the patient was continued on low dose amiodarone per ep recommendations. the patient went back into atrial fibrillation in the morning of in the setting of hypoxemia. metoprolol was unsuccessful and the patient was reloaded with iv amiodarone and spontaneously converted back into nsr. per family wishes, the aicd was turned off on the evening of . # respiratory failure: the patient had a subacute exacerbation with decline over past the past 3-4 weeks. he has copd at baseline and had recently been treated for a copd exacerbation and was on a prolonged steroid taper. he was electively intubated on to perform multiple procedures. subsequently, he had difficulty weaning from the ventilator, initially due to fluid retention in the setting of agressive iv fluid hydration required to support his blood pressure (he was 17l positive over his length of stay), as well as underlying copd. the patient was extubated on the afternoon of and was alert, however, he was reintubated on the morning of for worsening acidosis and hypoventilation with fatigue overnight. # acute renal failure: the patient initially presented with an elevated creatinine. initially this was felt to be pre-renal in the setting of sepsis and hypotension and urine lytes were consistent with this hypothesis. over time, however, his creatinine continued to rise and urine studies became consistent with atn. no urine eosinophils were identified, thus it was unlikely ain due to nafcillin. initial renal ultrasound suggested right-sided hydronoephrosis and urology was consulted, however, non-contrast ct scan subsequently showed no hydronephrosis. of note, the patient has a mass lesion on the left previously seen on ct done at bidn. his creatinine finally stabilized in the 4+ range. nephrology was also consulted to assist with management. they recommended phosphate binders to treat the patient's hyperphosphatemia and also considered performing renal biopsy, but deferred when the family decided not to persue any further interventions on and declined dialysis. all medications were renally dosed during the patient's stay. # septic and gouty arthritis: the patient had a known history of gout. on presentation he was initially given colchicine and prednisone was increased to 40 mg for presumed gout attack. rheumatology was consulted to aspirate his most painful joints. when the aspirations showed bacteria on gram stain, the steroids were decreased, but then increased again per rheumatology recommendations for gout and slowly tapered off. colchicine was stopped due to worsening renal failure. orthopedics was consulted and eventually took the patient to the or for washout on . all joints tapped had gpcs on gram stain and eventually grew mssa. # abdominal pain: several days after admission the patient developed abdominal discomfort on exam. abdominal ultrasound noted sludge in the gallbladder, no other findings were noted. lfts, amylase, lipase, were all within normal limits and tbili was mildly elevated. ultimately it was felt that the pain was secondary to bacteremia or some other process related to the patient's colon cancer. follow-up non-contrast ct scan of the abodmen and pelvis did not reveal any cause. contrast ct scan could not be performed secondary to renal failure. # anemia: the patient was likely anemic from gi bleeding from his colon cancer and also anemia of chronic disease. per bidn records his baseline hct was 35-37 prior to his diagnosis of colon cancer. he was transfused with 1 unit of prbcs on units on , and 1 unit on . hemolysis labs were negative. the patient was guaiac positive. # thrombocytopenia: the patient did have a decrease in his platelets which may have been multifactorial, including hit, uremia and dic. his platelets did stabilize in the 90s. # colon cancer: no known mets but with extensive lymphadenopathy in chest on last ct scan. he had an outpatient colorectal surgery appointment scheduled during his admission. further evaluation was deferred until his acute illness could resolve. # pressure ulcers: the patient had some sacral skin breakdown on admission. local wound care, frequent turns, special mattress, and close monitoring for areas of peripheral necrosis were performed. # hyperglycemia: the patient has no history of diabetes. his hba1c was 6.7. he was noted to be hyperglycemic shortly after admission, likely in part due to steroids. he was placed on an insulin sliding scale which was stopped on as he was no longer taking steroids and was not tolerating tube feeds at goal. # glaucoma: eye drops were continued per home regimen. # code status: the patient had previously been dnr/dni. he was electively intubated after discussion with both him and his wife as it was initially felt that his acute illness might be reversible. however, as the patient continued to do poorly despite antibiotic therapy and additional support, the family eventually decided not to persue further agressive therapy and provide comfort measures only. medications on admission: (per surgery note from ) -lasix 40', -colchicine 0.6', -flomax 0.4', -simvastatin 20', -lopressor 75", -asa 325', -felodipine sr 5', -ntg prn, -advair 250/50 qid, -atrovent prn, -albuterol prn, -pilocarpine tid, -xalatan 0.005% opth, -brimerlinidine opth, -mvi, fish oil, vit a, vit c, vit e -ferrous sulfate 325 mg daily -finasteride 5mg daily -aldactone 25mg daily -prilosec 40mg daily -colace 100mg daily -senna -klonopin 0.5mg qhs -percocet 5-325 mg daily -prednisone 10mg - tapering through discharge medications: not applicable, patient deceased discharge disposition: expired discharge diagnosis: primary diagnoses: methicillin-sensitive staph. aureus bacteremia and sepsis metastatic septic arthritis due to mssa bacteroides fragilis bacteremia enterobacter cloacae pneumonia secondary diagnoses: coronary artery disease congestive heart failure gout colon cancer chronic obstructive pulmonary disease hypertension gastroesophageal reflux disease discharge condition: deceased discharge instructions: n/a followup instructions: n/a procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances arthrocentesis arthrocentesis synovectomy, knee local excision of lesion or tissue of bone, patella aspiration of bursa other arthrotomy, wrist other local excision or destruction of lesion of joint, wrist diagnoses: acidosis anemia, unspecified coronary atherosclerosis of native coronary artery pneumonia due to other gram-negative bacteria tobacco use disorder acute kidney failure with lesion of tubular necrosis unspecified essential hypertension severe sepsis aortocoronary bypass status mitral valve insufficiency and aortic valve insufficiency unspecified glaucoma methicillin susceptible staphylococcus aureus septicemia pyogenic arthritis, ankle and foot rheumatic heart failure (congestive) acute respiratory failure other emphysema automatic implantable cardiac defibrillator in situ anemia in neoplastic disease gouty tophi of other sites, except ear malignant neoplasm of rectosigmoid junction pyogenic arthritis, lower leg olecranon bursitis pyogenic arthritis, upper arm 

Answer: The patient is high likely exposed to