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: fall, weakness major surgical or invasive procedure: left picc line placement history of present illness: 84f with no known coronary disease but a history of dm/ htn/ hl, diastolic heart failure and known mod as, mild ai and breast ca who p/w proximal muscle weakness and dysuira. the morning of , patient went to urinate and had dysuria. she was unable to stand up from the toliet due to new proximal muscle weakness and ended up sitting there before rolling off to try to crawl to reach the telephone which rang intermittantly. she specifically denies any chest pain, palpitations, loss of consciousness, or staying flat on one part of her body or the other. at baseline, she is able to climb a flight of stairs before getting leg weakness, but no dyspnea/ chest pain. she also denies orthopnea or pnd prior or after the event. finally, her daughter found her and brought her to the ed. in the ed, initial vitals were 20:54 0 100.0 74 111/47 16 99% 4l. exam remarkable for 3/6 systolic ejection murmur, loudest at the base and radiated to the upper chest and neck. no pulsus parvus et tardus, preserved s2. lungs were ctab. labs remarkable for a creatinine of 1.4, ck: 4062 mb: 21 mbi: 0.5 trop-t: 0.25, wbc of 13.2 with 90% neutrophils. ua with large leuks, neg nitrites and many bacteria. imaging remarkable for head ct with small left parietal subgaleal hematoma. patient was given 1l ns as well as 650mg acetaminophen and 500mg po cipro. vs on transfer 98.2, 75, 138/66, 96% ra. upon arrivival to the floor, patient is rigoring. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. hypertension 2. hypercholesterolemia 3. type 2 diabetes - the patient was diagnosed approximately 15 years ago. 4. right-sided breast cancer status post excision and radiation - the patient is now on hormonal therapy. 5. aortic stenosis 6. recurrent urinary tract infections 7. diverticulosis 8. peripheral neuropathy 9. iron deficiency anemia 10. diastolic dysfunction 11. mild mitral regurgitation 12. cholesterol embolus of the left eye 13. lichen sclerosus past surgical history: 1. status post excision of breast cancer 2. status post bilateral cataract removal social history: born, used to work. married; has 2 children; h/o tobacco, quit 30yrs ago, social etoh family history: her father died in his 80's of heart attack and her mother in her 90's of stroke physical exam: admission physical vs: t= 99.2 bp= 128/42hr= rr= o2 sat= general: wdwn f with rigors. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthelasma. neck: supple with jvp of 7 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. 3/6 systolic flow murmur radiating to the carotids. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored although patient tachypnic, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ neuro: aaox3, cnii-xii intact b/l. muscle strength 3/5 les, able to break with pushing. discharge physical exam: vs: tm 98.7, tc 98.4, 137-182/66-83, hr 60-75, rr 20 i/o= length of stay +100cc wt 70.3kg tele: intermittent self-resolving svt gen: well appearing in nad. heent: jvp 8cm cv: rrr, 3/6 systolic murmur heard best at rusb with radiation to carotids, +s4 lungs: minimal crackles bilaterally extremities: trace edema bilaterally s/p mastectomy, rue swelling > lue. no erythema. neuro: 5/5 strength, no back pain, no sensory deficits pertinent results: ekg: ? new st depression/ cupping at i and ii. tall, peaked t waves throughout, consistent with prior. old ekg : from clinic: sinus rhythm at a rate of 65. the axis is normal. the pr interval is prolonged. otherwise normal ecg. persantine mibi study date of impression: no fixed or reversible perfusion defects. calculated ef equals 78%. admission labs 10:55pm wbc-13.2*# rbc-3.62* hgb-11.4* hct-34.4* mcv-95 mch-31.6 mchc-33.2 rdw-13.9 10:55pm neuts-90.2* lymphs-6.3* monos-3.3 eos-0.2 basos-0.1 10:55pm plt count-221 10:55pm glucose-86 urea n-40* creat-1.4* sodium-143 potassium-3.7 chloride-109* total co2-22 anion gap-16 10:55pm ck-mb-21* mb indx-0.5 ctropnt-0.25* 10:55pm ck(cpk)-4062* 01:00am urine rbc-1 wbc-13* bacteria-many yeast-none epi-0 01:00am urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-lg 01:00am urine color-yellow appear-hazy sp -1.010 09:07am pt-14.1* ptt-32.0 inr(pt)-1.3* 09:07am plt count-192 cardiac enzymes 10:55pm blood ck(cpk)-4062* 09:07am blood ck(cpk)-5532* 10:17pm blood ck(cpk)-5667* 04:07am blood ck(cpk)-4551* 04:35am blood alt-76* ast-136* ld(ldh)-410* ck(cpk)-2359* alkphos-65 totbili-0.3 05:56am blood alt-79* ast-93* ck(cpk)-1128* 05:55am blood alt-74* ast-65* ck(cpk)-498* alkphos-93 totbili-0.4 03:22am blood alt-79* ast-61* ck(cpk)-272* ck / liver function tests 10:55pm blood ck-mb-21* mb indx-0.5 ctropnt-0.25* 09:07am blood ck-mb-22* mb indx-0.4 ctropnt-0.45* 10:17pm blood ck-mb-41* mb indx-0.7 ctropnt-0.79* 04:07am blood ck-mb-27* mb indx-0.6 ctropnt-0.69* discharge labs 03:22am blood wbc-9.0 rbc-2.94* hgb-9.0* hct-28.0* mcv-95 mch-30.5 mchc-32.1 rdw-14.3 plt ct-237 03:22am blood glucose-152* urean-24* creat-1.3* na-145 k-4.1 cl-110* hco3-26 angap-13 03:22am blood alt-79* ast-61* ck(cpk)-272* 03:22am blood calcium-8.8 phos-3.7 mg-2.6 microbiology urine culture (final ): proteus mirabilis. >100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. beta streptococcus group b. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s blood cultures x2 2:00 am blood culture # 2. **final report ** blood culture, routine (final ): beta streptococcus group b. final sensitivities. sensitivity testing performed by sensititre. sensitivities: mic expressed in mcg/ml _________________________________________________________ beta streptococcus group b | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s penicillin g---------- 0.06 s vancomycin------------ 1 s imaging: shoulder views non trauma right study date of 11:12 pm three views of the right shoulder. other than minimal degenerative chagnes in ac joint this exam is normal. no fracture or dislocation. chest (single view) study date of 11:12 pm there is mild cardiomegaly and mild vascular congestion but no pleural effusion or pneumothorax. there are no displaced rib fractures and the partially visualized clavicle and scapula appear intact. rib series should be considered if concern for rib fracture is high. ct c-spine w/o contrast study date of 10:11 pm 1. no acute fracture or malalignment. 2. moderate multilevel degenerative changes, most pronounced at c3-c4, c5-c6, and c6-c7, as detailed above. note added in attending review: there is significant spinal canal stenosis at c3-c4, which may predispose the patient to spinal cord injury, with appropriate mechanism of injury. ct head w/o contrast study date of 10:10 pm no acute process. small left parietal subgaleal hematoma. ct chest/abd/pelvis lung bases: mild-to-moderate nonhemorrhagic pleural effusions are new with bibasilar atelectasis. hiatal hernia is moderate. ct abdomen: liver steatosis is diffuse and the liver enhances homogeneously without focal lesion. there is no evidence of intrahepatic biliary duct dilatation. the gallbladder is unremarkable. 8 mm spleen lesion is stable since (2;13). two other 5 mm and 6 mm hypodense spleen lesions are new (series 2, image 11) and they are too small to be characterized but probably benign. the adrenal glands and pancreas are unremarkable. the right kidney is normal. left kidney cyst measuring 11 mm was already assessed by son. multiple areas of scarring of the left kidney are stable. the aorta and the arterial vessels are heavily calcified. there is no pathologic lymph node enlargement by ct size criteria. air in the bladder is mostly related to prior bladder manipulation. the uterus and the ovaries are unremarkable. colonic and duodenal diverticulum are uncomplicated. there is no ascites or abscess. osseous structures: there is severe degenerative spine disease without any suspicious malignant lesion. conclusion: 1. there is no cause of infection found in this patient. there is no abscess. 2. mild-to-moderate bilateral pleural effusions are new. 3. two new, less than 1 cm, hypodense spleen lesions are too small to be characterized but probably benign. rue ultrasound impression: no evidence of right upper extremity deep vein thrombosis. post-picc placement chest x-ray findings: this film is taken with improved technique. the picc line tip is in the svc. it still projects slightly more laterally than is typically seen, but this could be due to vascular engorgement. the heart is moderately enlarged. there is pulmonary vascular redistribution and bilateral pleural effusions. findings are compatible with chf. transthoracic echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is severe aortic stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. severe aortic stenosis. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , aortic stenosis has progressed. there is slightly more mitral and aortic regurgitation. estimated pulmonary artery pressures are higher. brief hospital course: 84f with no known coronary disease but a history of dm/ htn/ hl, diastolic heart failure and known mod as, mild ai and breast ca who p/w fall at home earlier on the morning of , on the floor for 8 hours, developed rhabdomyolysis, hypotension, found to have group b strep bacteremia of unknown source. stabilized with fluids while in icu. # fever, sepsis, bacteremia: on morning of admission, pt developed fever of 102.9, hypotension with sbp into the 70s, despite ivf hydration, tachycardia. was transferred to the micu on hd1, stabilized with 7l ivf, called out to the floor on hd2. - blood cultures were positive for gram positive cocci in pairs & chains, speciated to group b strep (pansensitive). unclear etiology. - ct abdomen and pelvis - no evidence of infection - rue us, no evidence of dvt to explain swelling--most likely from lymphedema from breast cancer s/p excisions and radiation treatment - urosepsis also a possibility, as gbs 10,000-100,000 organisms/ml did grow out of urine. - id consulted - started on empiric vanc & ceftriaxone pending culture data, gave fluid bolus, then transferred to the micu for further workup and management of sepsis. - blood cultures x2 were positive for gram posiive cocci in pairs & chains, final speciation of group b strep - urine cultures grew pansensitive proteus mirabilis >100,000 organisms/ml and gbs 10,000-100,000 organisms/ml - antibiotics narrowed to ceftriaxone alone on - tte shows severe aortic stenosis, high risk of endocarditis in setting of gbs bacteremia, so we opted not to do tee. will treat empirically for endocarditis with 4 weeks of iv antibiotics. # rhabdomyolysis - likely secondary to prolonged immobilization, on ua 1 rbc and moderate blood, ck > 20x upper limit. on admission, cr was 1.6, which was near baseline (1.3-1.8). does endorse some proximal muscle weakness / inability to rise from toilet, but more likely generalized weakness in the setting of sepsis. - consider workup for inflammatory myositis if proximal muscle weakness persists after resolution of infection - statin-induced rhabdomyolysis is unlikely given acute onset, but held atorvastatin during hospitalization; restarted on discharge - ivf, monitor for pulmonary edema / dyspnea given history of diastolic heart failure - creatinine improved markedly with volume resuscitation and source control from peak of 1.5 to 1.1 upon transfer back to floor from icu, on discharge was 1.3, which is near baseline. # elevated cardiac enzymes: elevated troponin and ck in setting of proximal muscle weakness and 8 hours of immobilization on the floor after fall. troponin bump most likely to infection, severe as, lvh. was started on a heparin drip overnight on night of admission for possible acs, but was discontinued prior to transfer to the unit as demand myonecrosis was the most likely explanation for elevated cardiac enzymes, and suspicion for acs was low. ecg was unconcerning. pt complained of no chest pain or shortness of breath. - most likely had demand ischemia to as and lvh. no evidence of focal wall motion abnl, concerning ecg changes for ischemia. - cardiac echo showed lvef 55% and severe aortic stenosis ( 0.8cm2) with moderate pulmonary hypertension (pasp 43mmhg) - ck significantly elevated & initially trended up 4062->5032, mb stable 21->22, troponin 0.2->0.45, all of which resolved with control of her infection and volume resuscitation # as w/ diastolic chf: h/o chf with preserved systolic function (lvef > 55%), severe as, mild ar. c/o dyspnea but appears euvolemic, lungs clear to auscultation bilaterally. due to cxray c/w chf after volume resuscitation, patient was iv diuresed x1, with good output. then placed on home lasix. - during this hospitalization, net even i=o. - no need to perform as w/u now in setting of infection. will need for her to recover and see if she is symptomatic from her as. - furosemide 20 mg, lisinopril 40 mg, metoprolol held while septic, but gradually restarted. - monitored resp status closely given ivf hydration for rhabdomyolysis as above, pt appeared clinically euvolemic and was satting well on ra, but cxr showed worsening fluid status, so diuresed with 20mg iv lasix once then transitioned back to home lasix. - no urgent need for aortic valve surgery. will need evaluation for avr after infection resolved. # weakness: has diffuse joint pain and muscle aches. not weak on exam. no focal signs. no spinal tenderness. unlikely to have sea. no clinical evidence of focal abscess at this time. # rue swelling: is s/p mastectomy & ln excision. mildly hypervolemic due to ivf in icu for sepsis. no erythema or fevers to suggest infection. no focal tenderness - rue ultrasound confirmed no clot # transaminitis: mild transaminitis, trending down. likely etiology: congestive hepatopathy, fatty liver (as evidenced by ct scan) - trend weekly as outpatient per opat - consider hepatitis panel as outpatient for r/o. most likely nash given ct findings of diffuse liver steatosis # svt: episodes of aflutter/svt, which patient notes treating at home with carotid massage. - continue metoprolol. # uti: proteus - treat for week long course given diabetes, on ceftriaxone for gbs bacteremia as above. # stage iv ckd: 1.3-1.8 is approximate baseline. cr peaked at 1.5 during this hospitalization despite rhabdomyolysis. patient is at lower end of baseline currently. - avoid nephrotoxins - renally dose medications # hypertension: originally hypotensive, so held all home meds. day before discharge, was hypertensive (bp 135-180), restarted all home meds previously held for hypotension. - consider adding calcium channel blocker as outpatient if hypertension persists. # subgaleal hematoma s/p fall - no change in mental status healthcare maintenance # dm: a1c of 6.1 on - held home glipazide, restarted on discharge - hiss # spinal stenosis: had started pregabalin recently. chronic problem # osteoporosis: - alendronate sodium 70 mg po qsun - calcium carbonate 1500 mg po/ng daily - vitamin d 400 unit po/ng daily # h/o breast ca: - anastrozole *nf* 1 mg oral daily # med rec: - ferrous sulfate 325 mg po/ng daily # anemia: stable. f/u as outpatient #code: full confirmed transitional issues: # follow up for aortic stenosis with dr. # continue abx for 4 weeks duration. follow up w/ infectious disease in clinic while at rehab # f/u lfts and liver steatosis medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. acetaminophen 650 mg po q8h:prn pain 2. lisinopril 40 mg po daily 3. clobetasol propionate 0.05% cream 1 appl tp prn itching 4. pregabalin 25 mg po tid 5. anastrozole *nf* 1 mg oral daily 6. metoprolol tartrate 100 mg po bid 7. alendronate sodium 70 mg po qsun 8. atorvastatin 80 mg po daily 9. ferrous sulfate 325 mg po daily 10. furosemide 20 mg po daily 11. cranberry extract *nf* unknown oral unknown 12. calcarb 600 with vitamin d *nf* (calcium carbonate-vitamin d3) 600 mg(1,500mg) -400 unit oral 13. aspirin 81 mg po daily 14. glipizide 5 mg po daily discharge medications: 1. alendronate sodium 70 mg po qsun 2. anastrozole *nf* 1 mg oral daily 3. aspirin 81 mg po daily 4. ferrous sulfate 325 mg po daily 5. furosemide 20 mg po daily 6. lisinopril 40 mg po daily 7. metoprolol tartrate 100 mg po bid 8. ceftriaxone 2 gm iv q24h 9. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 10. acetaminophen 650 mg po q8h:prn pain 11. atorvastatin 80 mg po daily 12. calcarb 600 with vitamin d *nf* (calcium carbonate-vitamin d3) 600 mg(1,500mg) -400 unit oral 13. clobetasol propionate 0.05% cream 1 appl tp prn itching 14. cranberry extract *nf* 1 tab oral daily 15. glipizide 5 mg po daily 16. pregabalin 25 mg po tid 17. outpatient lab work weekly cbc with diff, creatinine, alt, ast, esr, crp. fax results to clinic discharge disposition: extended care facility: - discharge diagnosis: primary: sepsis/bacteremia secondary: rhabdomyolysis, aortic stenosis, congestive heart failure, hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mrs. , it was a pleasure caring for you during your recent hospitalization. you suffered a fall and developed a condition called rhabdomyolysis (breakdown of muscle) from being on the floor for a prolonged period of time, for which we treated you with iv fluids. you were found to have an infection in your bloodstream, for which you will complete several weeks of iv antibiotics. transition of care - you will need to complete 4 weeks of iv antibiotics, you will have weekly blood tests and follow-up in the infectious disease clinic medication changes - start iv ceftriaxone 2g daily, take as directed by the infectious disease clinic followup instructions: you will be contact by the infectious disease clinic with a plan for outpatient follow-up of your bloodstream infection. if you do not hear from them in 5 business days, please call their office to set up an appointment: name:infectious disease operating unit: office location:w/lmob-gb office phone:( office fax:( procedure: central venous catheter placement with guidance diagnoses: congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified aortic valve disorders personal history of malignant neoplasm of breast personal history of tobacco use other and unspecified hyperlipidemia other specified cardiac dysrhythmias osteoporosis, unspecified septic shock iron deficiency anemia, unspecified streptococcal septicemia unspecified hereditary and idiopathic peripheral neuropathy spinal stenosis, unspecified region rhabdomyolysis diverticulosis of colon (without mention of hemorrhage) chronic diastolic heart failure other acute and subacute forms of ischemic heart disease, other 

Answer: The patient is high likely exposed to