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: altered mental status major surgical or invasive procedure: mvr(29mm tissue) return to or for chest exploration 2nd to bleeding history of present illness: ms. is a 47yo woman with hcv cirrhosis, emphysema, heroin ivdu, who was recently admitted from for septic shock, mssa mv endocarditis () c/b septic emboli to the brain, spleen, kidneys, and digits (w necrosis of distal extremities). course was complicated by klebsiella hcap (sp 8d levofloxacin; bal on also showed 2+ budding yeast), (cr 1.1 --> 3.1), e. coli uti (dx: ; sp 7d ciprofloxacin) and /glabarta peritonitis (dx ; sp micafungin and flagyl). pt was not ct candidate as per ct team (tee on showed mv vegetation: 2.4x1.4cm and on showed mv vegetation, measuring 1.3 cm x 0.9 cm). pt was treated with vanc and later discharged on nafcillin (day 1 - ). pt presented again on s/p unwitnessed fall w/ neck pain. in , pt was found to be febrile (102.3), tachycardic (120-140s), sob w o2 sat to 90s on 3lnc. exam was notable for being combative and agitated, and pansystolic murmur best heard over the apex, and slight diffuse abdominal tenderness. extremities were still notable for necrotic fingers and feet with 2+ pulses bilaterally. in ed, ct head was negative, ct spine showed possible c5-6 diskitis (focal endplate irregularities and sclerosis), cxr showed bl hazy opacities, and cta chest showed lingular nodule and multiple nodularities w fluid overload pattern and no pe. echo showed a moderate-sized vegetation on the mitral valve (posterior leaflet) and severe (4+) mitral regurgitation. csurg was reconsulted for evaluation for mitral valve replacement. past medical history: recent icu admission for mssa endocarditis, c/b septic shock, respiratory failure, pneumonia, atn, hand/foot necrosis, fungal peritonitis, uti, hep. c not treated(being followed at ), asthma, vit. d deficiency, asthma, emphysema social history: currently separated from wife prior to admission because of patient's polysubstance abuse. pt actively using heroin, mj, bz, cocaine, before last admission. approximately 35 pack year smoking hx. two sons (24, 16). two grandchildren family history: father deceased lung ca brother deceased all uncle deceased ca + copd son bladder ca physical exam: admission temp: 98.6 pulse: 116 b/p: 122/85 resp: 22 o2 sat: 100%ra height: 65" weight: 75kg general: nad, a&ox3 skin: dry intact , gangrenous feet bilat, necrotic fingertips bilat. heent: eomi neck: full rom , +trach w/ puissy muir valve chest: +rhonchorous heart: murmur - systolic grade ______, tachy w/ reg rhythm abdomen: soft non-distended non-tender +bs extremities: dry gangrene of b/l distal phalanges, r>l. dry gangrene of b/l feet (mid-foot to toes). neuro: grossly intact discharge: vs: 99.2 97 reg 105/77 18 100% ra wt 76.6 gen: nad-lying in bed neuro: a&o x3, nonfocal exam pulm: clear, diminished in bases bilat. trach site cdi cv: rrr, sternum stable, incision cdi abdm: soft, nt/nd/+bs. peg site tender to touch/cdi ext: necrotic feet bilat-dopplerable pt pulse necrotic fingertips- bilat pertinent results: mri head 1.evolution of multiple abnormal flair foci, in keeping with infarcts, throughout the brain parenchyma with some of them demonstrating more apparent hemorrhagic components. different degrees of decreased flair intensity involving some of the multiple infarcts. no evidence of acute infarct. 2. the area of concern corresponds to expected evolution of a focal infarct within the left cerebellum. no evidence of abnormal enhancement. ct torso impression: 1. no evidence of pulmonary embolism. 2. worsening of the bilateral nodular pulmonary densities, most likely infectious versus inflammatory in nature. these should be followed with repeat ct when the patient's current clinical scenario improves to assure complete resolution. there is also worsening of the lower lobe atelectasis and consolidations as well as worsening of the mediastinal lymphadenopathy. pulmonary edema is similar in extent. 3. stable splenic and renal infarcts. 4. thrombosed right external iliac artery, an unchanged finding. 5. increased size of a left adnexal cyst. if patient is postmenopausal then further evaluation is recommended with pelvic ultrasound on a nonurgent basis (within 6 weeks). ct of the abdomen with iv contrast : included views of the lung bases demonstrate small basilar consolidations, mild interstitial edema, moderate emphysema, and multiple scattered ground-glass nodular opacities, all improved since the chest ct examination. small left pleural effusion. the heart size is normal. there is no pericardial effusion. relative hypodensity of the blood pool with respect to the intraventricular septum (2:6) is compatible with chronic anemia. there has been interval resolution of previously-seen ascites. the liver contour is nodular, most compatible with cirrhosis. the spleen is mildly enlarged and contains a splenic infarct in the lateral upper pole (2:12). the pancreas, adrenal glands, stomach, and intra-abdominal loops of small bowel are normal. a gastrostomy tube is appropriately positioned (2:31). relative hypodensity of the superior spleen (2:14) and along the right renal cortex (2:29. 27) are better appreciated on the contrast-enhanced study from , reflecting infarcts. scattered prominent para-aortic lymph nodes (2:32) are slightly enlarged since the examination. echo report the left atrium is normal in size. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are moderately thickened. there is a moderate-sized vegetation on the mitral valve. there is an abscess cavity seen adjacent to the mitral valve (not as well seen as on the prior transesophageal echocardiogram). moderate to severe (3+) to severe (4+) eccentric mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. compared with the prior transesophageal study (images reviewed) of , the mitral vegetation now appears smaller. mitral regurgitation appears similar to slightly worse (severity of mitral regurgitation was likely underestimated in the prior report). an abscess/phlegmon is seen along the posterolateral annulus (though not as well seen as on the prior transesophageal echocardiogram). pre bypass no thrombus is seen in the left atrial appendage. mild spontaneous echo contrast is seen in the body of the right atrium. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. overall left ventricular systolic function is normal (lvef>55%). there is an echolucent area in the basal lateral and anterlateral walls, below the posterior mitral annulus, that demonstrates blood flow within. this is likely an aneurysm due to abscess. the right ventricle appears to dispaly focal hypokinesis of the apical free wall. this may be due to limited imaging. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. no masses or vegetations are seen on the aortic valve. there is a large vegetation on the mitral valve. the mitral regurgitation vena contracta is >=0.7cm. severe (4+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results in the operating room at the time of the study. post bypass there is normal biventricular systolic function. there is a bioprosthesis located in the mitral position. it appears well seated and displays normal leaflet motion. no mitral regurgitation is appreciated. the maximum gradient through the mitral valve was 15 mmhg with a mean gradient of 5 mmhg at a cardiac output of 6.5 liters/minute. the tricuspid regurgitation may be slightly worse but is mild in total. the rest of valvualr function is unchanged. the thoracic aorta is inatct after decannulation radiology report chest (portable ap) study date of 3:54 pm final report there is no evident pneumothorax. moderate pulmonary edema has worsened. right lower lobe and right perihilar opacities have increased consistent with increasing atelectasis and pleural effusion. left lower lobe retrocardiac opacities have worsened, consistent with worsening atelectasis. swan-ganz catheter tip is in the main pulmonary artery. right picc tip is in the middle svc. tracheostomy tube in standard position. cardiomediastinal contours are unchanged. small left pleural effusion has increased. discharge labs: 05:36am blood wbc-5.6 rbc-2.86* hgb-9.1* hct-27.6* mcv-96 mch-31.6 mchc-32.9 rdw-18.9* plt ct-102* 06:30am blood wbc-6.4 rbc-3.16* hgb-9.7* hct-29.9* mcv-95 mch-30.8 mchc-32.5 rdw-18.7* plt ct-93* 02:34am blood wbc-8.0 rbc-2.79* hgb-8.8* hct-26.2* mcv-94 mch-31.5 mchc-33.5 rdw-18.6* plt ct-82* 05:36am blood urean-12 creat-0.6 na-134 k-3.5 cl-103 06:30am blood glucose-111* urean-13 creat-0.6 na-133 k-3.3 cl-101 hco3-23 angap-12 02:34am blood glucose-136* urean-12 creat-0.6 na-135 k-3.5 cl-103 hco3-23 angap-13 04:00pm blood glucose-149* urean-11 creat-0.6 na-130* k-3.7 cl-101 hco3-21* angap-12 brief hospital course: medical course: 47 yo f with a history of hcv, ivdu, recently d/c from icu to rehab on after 1 month inpatient stay for mssa endocarditis (was on nafcillin) c/b shock, respiratory failure s/p trach, pneumonia, to atn, hand and foot necrosis and fungal peritonitis who was admitted after fall at rehab with complaints of fevers, tachycardia 1) respiratory distress: the patient had intermittent desaturations in the ed. upon presentation to the icu, was initially doing well. was found to have passey muir valve in place, and reported leaving it in place for over a week without taking out in evenings. valve was removed. patient quickly desaturated to 60s-70s, rr 30s, hr 150s-160s, bps 150s/90s-100s. became combative, agitated. large mucous plugs were suctioned along with albuterol nebulizer, 2 mg iv ativan, and 100% o2 to bring her up to o2 sats in the 80s. she briefly required ventilatory support with a peep of 5cmh2o and pressure support of cmh2o. her respiratory status improved with suctioning and humidified oxygen. she was instructed to remove her passey-muir valve overnight to improve pulmonary hygeine. ultimately, it was felt that the single desaturation event was secondary to mucous plugging, which was itself secondary to continuous use of passey muir valve. she was sent to the floor on trach mask at 40% fio2. on the medical floor, her respiratory status stabilized, and did well with intermittent suctioning and maintained adequate cough. on sputum cx grew colonies of chryseobacterium and stenotrophomonas (xanthomonas) maltophilia. as pt was afebrile and had no leukocytosis, id team felt that there was no need for additional antibiotic coverge as this was most likely benign colonization. 2) fever likely secondary to hcap and mssa endocarditis: the patient was febrile to 102.3 in the ed on initial presentation. contributing sources included pneumonia--likely hcap (sputum culture grew pseudomonas), persistent mssa mitral endocarditis, possible cervical osteomyelitis/discitis as seen on cervical spine mri. in addition, elevated beta glucan raised potential of persistent or recurrent fungal peritonitis; ct was performed, which showed no intra-abdominal or intrapelvic fluid collections. ct, however, raised potential contribution of ?new thrombophlebitis in the right iliac; this was not immediately evaluated in icu pending improvement in renal function (for contrast load) and lack of acuity not requiring mra. as patient continued to spike fevers, the picc line was also pulled after placement of 2 peripheral ivs, and the picc line tip was cultured. her outpatient nafcillin was held and she was initially empirically treated with vancomycin 750mg iv q12h and cefepime 2g iv q8h. the antibiotic spectrum was again changed to nafcillin and cefepime in conjunction with id, with a plan for a total of 17 days of cefepime for the hcap, and a complete course of nafcillin of 8 weeks duration (ending on ). given peristant fevers on , a ct torso was performed, which revealed the possibility of another/new infectious lesion in the brain. for further evaluation, and mri of the brain was performed and revealed multiple septic emboli with hemorrhagic components. cardiac surgery was again consulted in re: the timing of any mvr. a repeat echocardiogram was requested by them to evaluate. this was performed and revealed severe (4+) mitral regurgitation was seen and mvr was done on . the explanted valve was sent to pathology and had cultures sent. 3) right external iliac artery thrombus: this was seen on a non contrasted study in the icu. there were also some subtle changed on prior imaging from prior hospitalization. a ct torso on demonstrated thrombosis of the rt. ext iliac artery, which radiology reported as 'an unchanged finding'. id and vascular surgery were asked for input as to further specific managment for this finding, if any, over concern for the possible need for anticoagulation given possible nidus of septic thrombophlebitis/ongoing endovascular infection, and recommended heparin drip and would readdress operation after mvr with cardiac surgery. heparin drip was started after vascular initially planned on operating on groin clot before c-. serial neuro checks were done while on heparin as pt had septic emboli to brain and had hemmorrhagic components. pt required a head ct after starting drip which ruled out hemorrhage. heparin drip was discontinued as risk of intracranial hemorrhage outweighed benefit of agressive anticoagulation for clot without interval change and not symptomatic (no wet gangrene of r le and doppler pulses of posterior tibialis). 4) c5-c6 chronic osteomyelitis with neck pain: the patient had a head and neck ct that suggested only discitis/osteomyelitis. there was no evidence of fracture. she had no focal neurologic findings on exam. her pain was treated with oxycodone prn, and antibiotic thearpy was continued as above. on pt complained of r shoulder pain (without neurologic deficits) and this was concerning for acute osteomyelitis- imaging should no signs of osteo. 5) dry gangrene on extremities: the patient's hands and feet show evidence of dry gangrene secondary to septic emboli. she was seen by plastic surgery who recommended waiting for the necrotic tissue to demarcate and folowup in 2 weeks. betadine was placed on hands and feet to prevent conversion from dry to wet gangrene. her extremities did not develop signs of wet gangrene during her hospital stay. vascular surgery saw pt. and recommended outpatient follow up in one month for possible amputation of the feet at a tma site or via bka (tbd). pt's pain was controlled with oxycontin, oxycodone for breakthrough, and tylenol. 6) neuropathic pain: the patient complained of burning pain in her legs that was thought to be neuropathic in nature. she was started on gabapentin 300mg po tid which was subsequently increased to 600 mg tid. 7) hep c: the patient's lfts and inr remained stable during her admission. she is not being treated for hep c currently, and no treatments were started during her admission. 8) trach/peg: per ip, was going to defer downsizing tube before surgeries as pt may need bronchoscopy and trach will be used by anesthesia for procedures. in addition, ip also planned on taking out peg tube after procedures as well. peg tube was not used while on medical floor as pt was able to swallow medications and food without difficulty. surgical course: 47f seen by cardiac surgery on during an admission for mssa bacteremia and mitral valve endocarditis with multiple embolic events (brain, spleen, r kidney, lesions), presumably secondary to iv heroin use. at the time of evaluation, pt was septic; thus, the initial decision was to treat her medically (vanc/zosyn -> nafcillin x 6 wks). she then defervesced, her blood cultures after were sterile, and a tee failed to show progression; thus, surgery was deferred even after she stabilized. her hospital course was also significant for klebsiella pneumonia/respiratory failure requiring trach (treated with levofloxacin x 8d), acute kidney injury (cr 3.1, presumed secondary to atn, secondary to hypotension), e.coli uti (treated with cipro x7d), and fungal peritonitis (treated with micafungin and flagyl). she was discharged to rehab on . on , pt was sent back to ed s/p fall out of bed with neck pain and agitation. in the ed, she was noted to be febrile (102.3), tachycardic (120-140s), and hypoxic (mid-low 90s on 3l). wbc was normal. ct and mri c-spine demonstrated c5-6 chronic osteomyelitis. cxr and cta chest demonstrated multifocal pneumonia. she was admitted to medicine. repeat echo demonstrated that the mv vegetation had decreased in size. again, an abscess/phlegmon along the posterolateral annulus was noted. mv regurgitation was noted to be similar/slightly worse. all blood cultures since readmission have been sterile. on pt was noted to be somnolent, febrile (100.8), and tachycardic. ct head demonstrated a new r vertex ring-enhancing lesion, ?early abscess. however, cta torso also demonstrated worsening pneumonia. csurg was reconsulted to re-evaluate for possible surgical intervention in the setting of continued septic emboli. echo showed moderate-sized vegetation on mitral valve. no ms. (4+) mr. on the patient was transferred to the cardiac surgical service. the patient was brought to the operating room on where the patient underwent mvr (29mm tissue). see operative report for full details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. later on the night of pod#0 she was taken back to the operating room for re-exploration for bleeding. pod 1 she was weaned from the ventilator and able to maintain adequate oxygenation on trach collar. she remained alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service and rehab was recommended. she is non-weight bearing due to her dry necrotic feet. by the time of discharge on pod 6 the patient was afebrile on iv nafcillin, tolerating a regular diet but remained on cycled tube feeds to maximize nutrition. she was eating well and so the tube feeds can likely be discontinued soon. trach and g tube removal to be evaluated at rehab once procedures completed. the sternal wound was healing and the pain in her extremities and sternum was controlled with oral analgesics. she is to continue nafcillin until via picc and had infectious disease follow up arranged. the day before discharge she experienced pain at her peg tube site but it was found to be clean, dry, and intact on inpection. dr. team, who placed the tube on , asked for a tube study that revealed that the tube was in in good position. they are hesitant to remove the tube in this malnourished patient until the tube has been in place for at least a total of 12 weeks due to the risk of peritonitis. the patient was discharged to on pod 6 in good condition with appropriate follow up instructions. cardiac surgery and vascular follow up have been arranged. medications on admission: albuterol inhaler puff ih q4h:prn wheeze acetaminophen 650 mg po q6h pain do not exceed 4g in one day artificial tears 1-2 drop both eyes prn dry eyes docusate sodium (liquid) 100 mg po bid hold for loose stools. nafcillin 2 g iv q4h endocarditis oxycodone (immediate release) 5 mg po q4h:prn pain in feet quetiapine fumarate 25 mg po hs:prn agitation, insomnia senna 1 tab po bid:prn constipation fluticasone-salmeterol diskus (100/50) 1 inh ih discharge medications: 1. nafcillin 2 g iv q4h 2. heparin 5000 unit sc tid 3. gabapentin 600 mg po tid 4. fluticasone-salmeterol diskus (100/50) 1 inh ih 5. senna 1 tab po bid:prn constipation hold for loose stools 6. acetaminophen 650 mg po q4h pain do not exceed 4g in one day 7. oxycodone (immediate release) 10 mg po q4h:prn pain in feet hold for sedation, rr < 10 8. albuterol 0.083% neb soln 1 neb ih q4h:prn wheezing 9. amitriptyline 25 mg po hs 10. aspirin ec 81 mg po daily 11. ipratropium bromide neb 1 neb ih q6h:prn wheezing 12. lorazepam 0.25 mg po q4h:prn anxiety 13. povidone iodine 1/2 strength 1 appl tp asdir hands and feet twice daily 14. ranitidine 150 mg po bid 15. oxycodone sr (oxycontin) 20 mg po q12h hold for sedation and/or rr < 10 16. metoprolol tartrate 12.5 mg po bid discharge disposition: extended care facility: in discharge diagnosis: primary diagnoses: mitral valve endocarditis s/p mvr with return to operating room for post-operative bleeding, pmh: pseudomonas pneumonia, mitral valve endocarditis-mssa, cervical osteomyelitis, necrotic finger tips and feet, hepatitis c, endocarditis, ivdu, , hand foot necrosis, fungal peritonitis, right iliac septic thrombus, , cirrhosis, asthma, emphysema, vit d deficiency, chronic headaches, psh: tracheostomy, peg discharge condition: alert and oriented x3 nonfocal, anxious at times lift to chair incisional pain managed with oxycodone and oxycontin incisions: sternal - healing well, no erythema or drainage legs with dry black necrotic feet. edema of both lower extremities: 2+ ue with nectrotic fingers bilaterally discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for one month or while taking narcotics. driving will be discussed at follow up appointment with surgeon. females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** infectious disease instructions: opat antimicrobial regimen and projected duration: & dose: nafcillin 2g iv q4h start date: stop date: cbc with differential (weekly) chem 7, bun/cr, ast/alt/alk phos/total bili, cpk, esr/crp -weekly all laboratory results should be faxed to the infectious disease r.n.s at (. all questions regarding outpatient parenteral antibiotics should be directed to the infectious disease r.n.s at ( or to the on-call id fellow when the clinic is closed infectious disease fellow: (first contact for patient-related matters, if unavailable please contact the id fellow on-call ) followup instructions: you are scheduled for the following appointments: surgeon: dr. on at 1:30p in the medical office building, , cardiologist: needs referral infectious disease clinic on at 09:00am in the medical office building, basement infectious disease fellow: (first contact for patient-related matters, if unavailable please contact the id fellow on-call ) vascular surgery: vascular lmob (nhb) phone: date/time: 10:15 bldg (), please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified extracorporeal circulation auxiliary to open heart surgery coronary arteriography using two catheters left heart cardiac catheterization incision of mediastinum open and other replacement of mitral valve with tissue graft diagnoses: tobacco use disorder mitral valve disorders cirrhosis of liver without mention of alcohol unspecified protein-calorie malnutrition unspecified viral hepatitis c without hepatic coma asthma, unspecified type, unspecified hemorrhage complicating a procedure pneumonia due to pseudomonas methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site other emphysema other and unspecified special symptoms or syndromes, not elsewhere classified acute and subacute bacterial endocarditis headache accidental fall from bed unspecified hereditary and idiopathic peripheral neuropathy other and unspecified coagulation defects tachycardia, unspecified gangrene embolism and thrombosis of iliac artery combinations of opioid type drug with any other drug dependence, continuous other respiratory abnormalities unspecified vitamin d deficiency other diseases of trachea and bronchus acute edema of lung, unspecified attention to tracheostomy attention to gastrostomy cervicalgia cellulitis and abscess of other specified sites other and unspecified disc disorder, cervical region chronic osteomyelitis, other specified sites septic arterial embolism other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation cerebral embolism without mention of cerebral infarction aseptic necrosis of bone, other 

Answer: The patient is high likely exposed to