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: no known allergies / adverse drug reactions attending: chief complaint: osh transfer for plasma pharesis evaluation major surgical or invasive procedure: knee washout, intubation history of present illness: 62-year-old male with history of multiple myeloma/plasma cell dyscrasia, type i cryoglobulinemia, chronic renal insufficiency, congestive heart failure, anemia and copd presents from osh with staphylcoccus aureus bacteremia, acute on chronic renal insufficiency, lower extremity edema for evaluation of plasma pharesis. . per osh records, the patient was in his usual state of health until recently when he received velcade and ecadron on and again on and was admitted for concern of tumor lysis syndrome. he improved and was discharged home. however, at home he continued be be very weak and developed progressive lower extremity edema. he missed his nephrology appointments although was able to keep an oncology appointment on . at that time he was admitted for bilateral leg edema. . on admission, he was afebrile, denied dysuria, polyuria, shortness of breath, cough, or other symptoms other than chronic pain and fatigue. his labs were significant for a wbc 17.4, hct 34.0, plt 108, bun 86, cr 4.24 (was 3.25 five days prior), uric acid 11.6, ldh 230. nephrology was consulted and thought that the patient had bilateral edema from acute on chronic renal failure, likely secondary to cryoglobulinemia. he was given lasix and steroids. over the next two days he had improvement of bun to 76, creatinine to 2.33 (eventual nadir 2.17) and worsening of thrombocytopenia (to 27). he developed hallucinations and had a head ct that was negative. he developed a bandemia of 15. he was pan cultured and diagnosed with a urinary tract infection. cxr without evidence of acute infection. he was started on levofloxacin. he continue to have altered mental status and deveoped hypotension to 99/63, fevers to 101f and rising wbc. blood cultures revealed 4/4 bottles with staphylcoccus aureus (sensitivities pending) and he was started on vancomycin. id was consulted and recommended iv antibiotics for 4-6 weeks and a tte. levofloxacin was discontinued. he became progressively altered and was transferred to the icu for further evaluation and management. . in the icu, head ct was done and was negative. abg was 7.57/32.9/89. he was noted to have hypoalbuminemia and relative hypotension. was started on ppn, albumin and given 1 u prbc. the day of transfer labs were wbc 5.4, hct 22.3, plt 12, bun 102, cr 2.22, albumin 1.3. vitals at time of transfer were t 97.8, bp 108/59 (per report baseline 140s), hr 110, rr 28, sao2 92% 4l nc. per signout, although no mention in notes, nephrologist states that he need dialysis. the reason for transfer is for evaluation for plasma pharesis. he was given 1uprbcs prior to transfer to . . on arrival to the , he was intermittently responsive to questions, reports all-over body pain and otherwise difficult to ascertain as patient not very responsive other than moaning to movement. he was intubated essentially on arrival for cxr showing ards and poor o2 saturation on 6l nc and facemask. 30 mins s/p intubation patient then dropped his bp to 50's, was given ivf bolus, cvl was placed in r femoral artery emergently and patient was given peripheral dopa, then levophed through the central line, and 0.1mg of epinephrine. his bp went up to 70's, then steadily increased to 160's, and pressors were weaned down. his art stick showed acidemia and a lactate that increased from 2.6 to 8.2. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - plasma cell dyscrasia (multiple myeloma), s/p 6 cycles of velcade and decadron in and restarted treatment recently with dr. , on and again on - type i cryoglobulinemia (1gg kappa light chain secondary to plasma cell dyscrasia) - cardiomyopathy ef 25-30% - restrictive cardiomyopathy from amyloid - congestive heart failure - chronic renal insufficiency currently stage 3(with aocrf in the setting of velcade tx in that required a month of dialysis) - anemia - h/o etoh abuse - htn - s/p mvc with trauma to the right leg with back flap to right anterior calf, right radial artery to right leg. on chronic narcotics including methadone and percocet - hyperlipidemia - copd - per pt's girflriend he has bacteremic meningitis 5 years ago with damage to his heart valves also. social history: he lives alone and has a girlfriend who helps with his care. history of etoh abuse, none since . history of tobacco use. none currently. motorcycle driver. on disability s/p motor vehicle accident. no etoh since , but heavy use prior. prior marijuana use. had worked in the iron industry and as a carpenter. family history: mother with chf. father with lung cancer in 50s. no premature cad/sudden death. physical exam: general: aaox1, appears in moderate distress, tachypneic heent: sclera anicteric, mucous membranes dry, no teeth neck: supple, jvp difficult to assess tachypnea and tachycardia lungs: anteriorly moderate rhonchi worse over l anterior lung field cv: regular rate and rhythm, difficult to assess for m/r/g as rhonchorous breath sounds very prominent over l side abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: r lower leg with chronic skin changes skin flap, and with large r pleural . discharge exam general appearance: anxious, oriented to person, hospital, year: eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition, dried blood in oropharynx and nasopharynx cardiovascular: blowing systolic murmur at llsb pulm: cta in anterior fields abdominal: soft, bowel sounds present, mild ttp, and involuntary guarding in epigastrium neurologic: responding to commands to grasp hands, intermittent response to questions skin: a 30cm x 10cm area of erythemia noted over the lateral aspect of his left thigh. pertinent results: admission labs: 09:20pm blood wbc-5.6 rbc-2.81* hgb-7.7*# hct-24.1* mcv-86 mch-27.5 mchc-32.2 rdw-18.4* plt ct-15*# 09:20pm blood neuts-87* bands-3 lymphs-3* monos-7 eos-0 baso-0 atyps-0 metas-0 myelos-0 09:20pm blood pt-14.6* ptt-30.8 inr(pt)-1.3* 09:20pm blood glucose-148* urean-109* creat-1.9*# na-144 k-3.9 cl-109* hco3-23 angap-16 09:20pm blood alt-11 ast-19 ld(ldh)-405* ck(cpk)-28* alkphos-66 totbili-3.4* 09:20pm blood albumin-2.1* calcium-7.5* phos-3.8 mg-2.5 uricacd-9.4* 02:38am blood crp-240.2* discharge labs 03:50am blood wbc-6.1 rbc-3.09* hgb-9.1* hct-26.4* mcv-85 mch-29.5 mchc-34.6 rdw-16.9* plt ct-109* 03:15am blood neuts-71.8* lymphs-17.6* monos-4.9 eos-5.1* baso-0.7 03:50am blood glucose-116* urean-31* creat-1.1 na-136 k-3.5 cl-106 hco3-25 angap-9 micro: urine culture (final ): staph aureus coag +. 10,000-100,000 organisms/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | gentamicin------------ <=0.5 s levofloxacin---------- =>8 r nitrofurantoin-------- 32 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s joint fluid fluid culture (final ): staph aureus coag +. moderate growth. staph aureus coag +. sparse growth. 2nd morphology. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | staph aureus coag + | | clindamycin----------- r r erythromycin---------- r r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r =>8 r oxacillin------------- 0.5 s 0.5 s trimethoprim/sulfa---- <=0.5 s <=0.5 s respiratory culture (final ): commensal respiratory flora absent. staph aureus coag +. moderate growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s imaging: ct chest w/o contrast study date of 11:33 am impression: 1. moderately large right acute pneumothorax with associated mediastinal shift to left and collapse of the right upper lobe. 2. multifocal predominantly upper lobe severe consolidation, in light of recent chemotherapy, fungal and viral infections are considered possible, although the pattern could also be described in bacterial pneumonia. adult respiratory distress syndrome is also considered possible, but the lack of a gravitational gradient makes this less likely. 3. bilateral moderately large pleural effusions. 4. mild pulmonary edema. portable tte (complete) done at 11:23:41 am final conclusions: the left atrium is mildly dilated. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed with inferior and septal akinesis/severe hypokinesis with mild to moderate hypokinesis elsewhere. the basal lateral wall moves best. (lvef= 25-30 %). the right ventricular cavity is mildly dilated with borderline normal free wall function. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is a moderate-sized vegetation on the anterior leaflet of the mitral valve (1.4 cm x 1 cm). an eccentric, laterally directed jet of moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . us left thigh fluid collection in the left lateral thigh with overlying inflammatory change. an infected collection is a concern with the history. . mri spine cervical spine: 1. 2.8 cm rim enhancing fluid collection, suspicious for abscess, in the right posterior paraspinal soft tissues adjacent to the right c4-5 facet. abnormal marrow signal adjacent to the joint may represent osteomyelitis or marrow edema. 2. increased stir signal within the c5-6 disc with adjacent epidural enhancing material suspicious for osteomyelitis, discitis with associated epidural phlegmon. this process combines with underlying degenerative changes to cause moderate spinal canal narrowing at this level. . thoracic spine: 1. numerous rim-enhancing fluid collections involving the left shoulder, partially evaluated, suspicious for abscesses. 2. ill defined, heterogenously enhancing material in the right anterior paraspinal soft tissues at t6-7 suspiucious for phlegmon. lumbar spine: 1. given history of recent septicemia, findings highly suspicious for infectious osteomyelitis of the bilateral l3-4 facet joints with adjacent abscesses in the posterior paraspinal soft tissues. at l3-l4, there is a posterior epidural component, which bows the cauda equina anteriorly, but does not cause high-grade spinal canal narrowing. 2. similar collections in the posterior paraspinal soft tissues at l4-5 and l5-s1 are also suspicious for abscesses, but with preserved marrow signal adjacent to these more inferior facet joints making osseous involvement less likely. . echo left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = 25 %). the mitral valve leaflets are mildly thickened. there is a moderate-sized vegetation (1.3 cm) on the mitral valve. moderate to severe (3+) mitral regurgitation is suggested. there is no pericardial effusion. . compared with the prior study (images reviewed) of , the lvef is lower and the lv cavity has increased in size. a tee would better assess the severity of mr and the mitral vegetation. . mri head impression: 1. two foci of acute infarction in the right anterior centrum semiovale and right posterior occipital lobe. . 2. persistent marked ventriculomegaly, slightly out of proportion to sulci. this could reflect central atrophy, or normal pressure hydrocephalus in the correct clinical setting. . 3. bilateral mastoid opacification. please correlate clinically for evidence of mastoiditis. brief hospital course: the patient is a 62 year old male with history of ischemic cardiomyopathy, plasma cell dysplasia with kappa light chains and cryoglobulinemia treated in , now s/p relapse and retreatment with resultant tumor lysis syndrome, acute on chronic kidney failure, and hospitalization at from to complicated by development of mssa septicemia, transferred to for further management. he was intubated soon after arrival, and found to have a septic right knee joint, multiple paraspinal abcesses, mitral valve endocarditis, and septic shock. after a lengthy and complicated hospital course, his care was transitioned to comfort measures only and he was discharged to health. . # goals of care: given overwhelming sepsis and multiple sources of infection, goals of care discussion was held with his health care proxy and his care was transitioned to comfort measures only. pain was managed with methadone iv standing and hydromorphone iv bolus as needed. he was transferred to health for hospice care. # septic shock: secondary to mssa bacteremia. on admission the patient was hypotensive requiring 3 pressors and epinephrine injection for support. he had positive cultures for mssa in blood from osh, as well as urine, knee aspirate, and sputum cultures at . he developed mitral valve endocarditis and septic arthritis (addressed below). infectious disease was consulted and recommended an extended treatment course with nafcillin. his blood pressure and urine output improved and his need for pressors resolved. . # endocarditis: he had stigmata of endocarditis with lesions on his left hand, and bilateral feet. echo on showed 1.0 x 1.4 cm vegetation on his mitral valve. ct surgery was consulted and recommended weekly ttes to monitor for interval change. he was treated with nafcillin extended course as above. repeat echo showed that mv vegitation had lessened in size to 1.3 cm. after goals of care discussion with hcp, care was transitioned to comfort measures only and antibiotics were discontinued. . # septic arthritis: he had a septic right knee with purulent aspiration with serial bedside washes and or washout on with arthrotomy with debridement, lavage, and synovectomy, as well as irrigation and debridement of his left elbow bursa. given persistent fevers, leukocytosis, and tachycardia he returned to the or on for repeat right knee wash out. . # paraspinal fluid collections: mri of the spine showed multiple fluid collections likely representing abcesses in the cervical and thoracic spine. given goals of care, comfort measures only were provided. . # left thigh fluid collection: a 30cm x 10cm area of erythemia was noted over the lateral aspect of his left thigh. ultrasound was consistent with fluid collection, likely representing an abcess. given goals of care, symptomatic management with pain control was performed. . # mental status: patient had depressed consciousness following extubation. mental status waxed an wained throughout hospitalization. concern for septic emboli was raised and he was sent for mri brain which showed acute infarcts in right anterior centrum semiovale and right posterior occipital lobe but no evidence of abcess. throughout the remainder of his icu course, he remained confused though responsive to simple commands, oriented to person, hospital, year:. . # hypoxic respiratory failure: patient was intubated shortly after arrival. chest ct on showed upper lobe consolidation and his sputum grew mssa, for which he was continued on nafcillin. he was also found to have a right pneumothorax on ct and a chest tube was placed by ip. his respiratory status improved and he was extubated on and transitioned to supplemental oxygen via nasal cannula. chest tube remained in place due to persistent bronchopleural fistula. tube was discontinued after goals of care discussion. . # anemia: the patient was noted to have a dropping hematocrit in the setting of coffee ground particles from his ng lavage, and blood in his oropharynx likely trauma from multiple ngt placements. he was started on an iv ppi and transfused as needed to maintain a hct >25 and plts > 50. ent was consulted and saw no evidence of active epistaxis. gi was consulted who noted stable hct and recommended against egd and continued medical management with pantoprazole. . # renal failure: acute on chronic renal failure. he has stage iii ckd and recent tumor lysis syndrome from velcade chemotherapy. his tls has since improved, with uric acid at osh from high of 11 down to 2.3, however elevated >8 at . his urine output was initially low, but after volume resuscitation he began to autodiurese with improvement in his uop to greater than 100cc/hr. he likely developed some degree of atn given his hypotension, which gradually resolved. . # multiple myeloma/cryoglobulinemia: last treatment was , which resulted in tls. total igg elevated (marginally). his spep showed less than 1% total protein igg kappa chains. no cryoglobulin was detected when checked on and his serum viscosity was just below the normal range. he was initially on stress dose steroids which were tapered off given the hematologic results. . # pain control: he has been having generalized body pain, likely due to septic arthritis and endocarditis, possibly with some contribution from his mm and chronic pain. he was started on methadone 20 mg iv q6h to wean off his fentanyl and midazolam drips. . #communication: girlfriend/hcp (cell) or (home) # code status:comfort measures only medications on admission: allopurinol 100mg po daily coreg 6.25mg po bid cymbalta 30mg po bid hydralazine 10mg po bid isosorbide dinitrate 10mg po tid methadone 10mg po up to 7x per day ms contin 30mg po tid potassium chloride 10meq daily endocet 10mg po up to 9x per day sodium bicarbonate 650mg po tid calcium carbonate plus d 600mg po daily discharge medications: 1. methadone 10 mg/ml solution sig: twenty (20) mg injection q4h (every 4 hours): hold for sedation . 2. hydromorphone 2 mg/ml syringe sig: 1-2 mg injection q2h (every 2 hours) as needed for pain: hold for sedation . 3. lidocaine hcl 2 % solution sig: twenty (20) ml mucous membrane tid (3 times a day) as needed for with mouth care. 4. acetaminophen 650 mg suppository sig: one (1) suppository rectal q4h (every 4 hours) as needed for fever: do not exceed 4000mg in 24 hours. 5. pantoprazole 40 mg recon soln sig: forty (40) mg intravenous q12h (every 12 hours). 6. sodium chloride 0.9 % 0.9 % parenteral solution sig: ten (10) ml intravenous prn (as needed) as needed for line flush: flush with 10ml normal saline daily and prn. discharge disposition: extended care facility: - discharge diagnosis: methicillin sensitive staphylococcus areus sepsis . endocarditis multiple abcesses acute cerebral infarction toxic metabolic encephalitis gastrointestinal bleed discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: dear mr. , you were transferred from an outside hospital to the intensive care unit for further evaluation and treatment of your infection. after a long discussion with your loved ones, it was decided to transiton our goals of care to making you as comfortable as possible by treating your pain and other symptoms. you are being transferred to another facility where the focus will be on making you pain free. followup instructions: none md procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization arthrocentesis arthrocentesis arthrocentesis synovectomy, knee other arthrotomy, knee bursotomy repair of blepharoptosis by tarsal technique bursectomy central venous catheter placement with guidance diagnoses: other primary cardiomyopathies thrombocytopenia, unspecified hypocalcemia acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified toxic encephalopathy severe sepsis chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified methicillin susceptible staphylococcus aureus septicemia chronic kidney disease, stage iii (moderate) acute respiratory failure cellulitis and abscess of leg, except foot blood in stool septic shock chronic systolic heart failure multiple myeloma, without mention of having achieved remission acute and subacute bacterial endocarditis encounter for palliative care other disorders of plasma protein metabolism hyperosmolality and/or hypernatremia intraspinal abscess cerebral artery occlusion, unspecified with cerebral infarction other paraproteinemias pyogenic arthritis, multiple sites olecranon bursitis tumor lysis syndrome 

Answer: The patient is high likely exposed to