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: sedatives, barbiturate, classifier attending: chief complaint: unwitnessed fall at home/ facility, rapid heart rate major surgical or invasive procedure: picc line placement central line placement history of present illness: mrs. is a -year-old female with pmh significant for atrial fibrillation,htn, breast cancer (s/p mastectomy ), hypothyroidism, who was originally admitted on following an unwitnessed fall at home. prior to ed arrival the patient had been evaluated by her pcp at her facility for left shoulder pain which was felt to be due to an effusion. according to patient she went into her bathroom, remembers sitting on the toilet, then she fell to the floor. she did not recall feeling lightheaded or dizzy. she denied any palpitations, chest pain, or acute onset of shortness of breath. she did not believe that she lost consciousness and could recall details of her entire fall. patient believes she was on the floor for a few hours because she found it very difficult to pull herself up. she reported that she thought she may have hit her head and left shoulder. . in the ed her initial vitals were t 98f, hr 156, bp 160/80, rr 22, and o2 sat 95% on ra. she was found to be in rapid atrial fibrillation to the 150's and was started on a diltiazem drip with initial good effect. she received a dose of ciprofloxacin for a positive ua in the setting of a leukocytosis to 19. ct of the head and neck were negative for any fractures, and no intracranial bleeds were noted. bilateral shoulder x-rays were negative for fractures or dislocations. . at time of arrival to the medical floor patient's rate was down to the 60's-70's. she denied any palpitations, cp or sob. her main complaint was left sided shoulder pain, which had been chronic for some time. she denied any recent illnesses including uri symptoms, urinary symptoms, diarrhea, nausea or vomiting. she reported poor appetite for a few days. . . on the medical floor, she subsequently had multiple triggers for atrial fibrillation with rvr. blood cultures from admission grew gpc so she was started on vancomycin on . due to complaints of left shoulder pain, she then underwent arthrocentesis of the left shoulder. culture of the joint fluid ultimately yielded mssa, as did multiple blood cultures ( from , from , and from ). she was seen by the cardiology service who recommended changing her from diltiazem for metoprolol. . of note, her fluid balance remained positive throughout the beginning of her hospital course, and her weight increased from 68->73kg. due to concern over arf, she received ivfs and she then developed fluid overload, pulmonary edema and hypoxia which required transfer to the micu for stabilization. her micu course was complicated by afib/flutter with rvr occasionally requiring iv nodal agents. she was aggressively diuresed in the micu with iv furosemide and at time of transfer, her shortness of breath had abated and her oxygen saturation level was much improved to 96% on 5l nc. . once she stabilized she was transferred to /cardiology service for ongoing management and continued on diltiazem drip for rate control. at time she transferred out of micu, she was receiving diltiazem extended-release 300 mg po daily and metoprolol tartrate 25 mg po tid, with additional iv agents as needed. the patient's bacteremia was felt to be related to an underlying endocarditis. echocardiogram on showed ef of 70%, mild as, and at least moderate 2+ mitral regurgitation. no comparisons existed in our system. patient was also complaining of diffuse generalized abdominal pain that had been present for 2 days near the end of her micu course prior to transfer to cardiology service. the patient had not had a bowel movement in about 4 days. surgical service was called due to preliminary read on abdominal ct which showed sbo and incarcerated right inguinal hernia which was reported to be at transition point near terminal ileum. surgery consult called and evaluation on the floor found that hernia was reducible. primary team placed ngt for ease of her abdominal pain and distension from sbo/ileus. surgical options were limited due to multiple co-morbidities, especially her bacteremia, suspected endocarditis, unstable atrial fibrillation with rvr and her ongoing dyspneic episodes. this prompted multiple discussions with patient and family surrounding goals of care during the last days of her hospital course. the palliative care service had been following the case and had multiple patient/family meetings. she pulled her ngt out on two occasions and her mentation was less clear toward the end of her hospital course. she was given low doses of morphine, tylenol, and anti-emetics for sbo-related abdominal pain control. ultimately, the patient's family (hcp/son) asked for no additional invasive measures, especially surgery. code status was changed to dnr/dni, and she was soon made comfort measures only per family's wishes. sadly, she passed away soon thereafter on the morning of . past medical history: -breast cancer, s/p l mastectomy in -atrial fibrillation, rate controlled on metoprolol, unclear if on coumadin -hypothyroidism -hypertension -? ra -htn -h/o falls -oa, djd hips/knees -uterine prolapse social history: lived at foley senior house/ center. used to live in and worked as administrative assistant. she enjoys painting. she has nursing assistance at facility to help with her medications. smoked cigarettes for 20-30 years and quit 50 years ago. denies any etoh use. no prior drug use history. she is wheelchair bound due to multiple prior falls. family history: non-contributory physical exam: initial admission exam: vitals 98.5f, hr 144, bp 141/86, rr 19, o2 sat 92% on 5l general thin elderly woman moaning heent sclera anicteric, conjunctiva pale, dry mm neck +jvd pulm lungs with occasional wheeze bilaterally (exam limited by patient pain on movement) cv tachycardic irregular s1 s2 soft systolic murmur at apex abd soft nontender +bowel sounds extrem warm 2+ distal pulses 2+ bilateral le edema. l shoulder very tender to light touch. neuro alert and awake, oriented x3 and attention intake. moving all extremities. derm no peripheral stigmata of endocarditis . . exam on transfer out of micu to the cardiology service: hr 130s, bp 118/72, o2sat 95% on 6l nrb, rr 28, afebrile gen: pallid, frail appearing female with slight nasal flaring but no accessory muscle use, no complaints of pain heent: nc/at, eomi, perrla neck: jvp at 8-9cm, supple cor: irregular rhythm, rapid rate. s1 and s2 appreciated, loud s2 and 3/6 systolic flow murmur at sternal border, no rubs, 2+ carotids b/l pulm: coarse breath sounds over anterior lungs/upper posterior fields and decreased lung sounds at bases bilaterally. she has large left breast mastectomy scar and a small scabbed over sore over left chest about size of a quarter, rounded. no active bleeding or discharge at site. abd: diffuse distension, soft, +extreme tenderness at rlq and mild tenderness over umbilical area, + rebound tenderness, reducible right inguinal hernia noted. ext: pitting edema of lower extremities bilaterally pertinent results: admission labs: 11:17am glucose-150* lactate-2.2* na+-139 k+-3.5 cl--98* tco2-23 11:17am freeca-1.06* 11:10am glucose-156* urea n-44* creat-1.5* sodium-137 potassium-4.0 chloride-97 total co2-24 anion gap-20 11:10am calcium-9.2 phosphate-3.5 magnesium-2.2 11:10am neuts-79* bands-3 lymphs-8* monos-10 eos-0 basos-0 atyps-0 metas-0 myelos-0 11:10am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 11:10am pt-15.3* inr(pt)-1.3* 11:10am plt count-288# urine studies: 11:00am urine color-amber appear-clear sp -1.019 11:00am urine blood-lg nitrite-neg protein-100 glucose-neg ketone-tr bilirubin-sm urobilngn-1 ph-5.0 leuk-tr 11:00am urine rbc-0 wbc- bacteria-mod yeast-mod epi-0-2 trans epi-3.5 11:00am urine hyaline-* 11:00am urine amorph-few . cardiac enzymes 08:50pm ck(cpk)-686* 08:50pm ck-mb-12* mb indx-1.7 ctropnt-0.03* 11:10am ck(cpk)-1585* 11:10am ctropnt-0.02* 11:10am ck-mb-22* mb indx-1.4 06:10am blood ck-mb-7 ctropnt-0.02* . labs : 06:59am blood wbc-36.2* rbc-4.69 hgb-13.9 hct-40.4 mcv-86 mch-29.6 mchc-34.4 rdw-13.8 plt ct-430 06:59am blood glucose-147* urean-35* creat-1.3* na-141 k-3.7 cl-101 hco3-25 angap-19 06:59am blood mg-2.0 . bnp level: 04:34am blood probnp-* . abg studies: 04:35am blood type- po2-103 pco2-39 ph-7.34* caltco2-22 base xs--4 intubat-not intuba . lactate: 09:32pm blood lactate-2.2* . additional studies: . ct head: no evidence of fracture, hemorrhage or acute finding. chronic small vessel ischemic disease and age-related parenchymal change. . cxr : extensive costochondral calcification again results in apparent opacities projecting over the lower lobes bilaterally, particularly on the right. there is no focal consolidation or superimposed edema. there is a tortuous atherosclerotic aorta, which remains well defined in its descending extent and stable from the prior exam. the cardiac silhouette size remains enlarged but also stable. no definite effusion or pneumothorax is seen. the bones are diffusely osteopenic which reduces the sensitivity for detecting subtle nondisplaced fracture. within that limitation, there is suggestion of a right scapular fracture. . b/l shoulders, three views: left shoulder: the bones are severely osteopenic which reduces the sensitivity for detecting subtle nondisplaced fracture. within that limitation, no fractures are evident. the glenohumeral and acromioclavicular articulations are within normal limits. the regional soft tissues are unremarkable. the visualized adjacent lung is clear. right shoulder: similar to the left, there is severe osteopenia which limits the evaluation. within that limitation, no fractures or dislocations are evident. the regional soft tissues are unremarkable. the visualized adjacent lung is clear. impression: no radiographic evidence for bony trauma to either shoulder within the limitation of severe baseline osteopenia. . ct c-spine without iv contrast: there is no fracture or malalignment. there is mild linear lucency which likely represents artifact traversing the left articular facet of c7 and t1 vertically. there is grade 1 anterolisthesis of c6 on c7. the lung apices demonstrate septal thickening, which can be seen with volume overload. a small amount of intravenous air is incidentally noted. soft tissues are otherwise unremarkable. . cxr: impression: diffuse overall increase in haziness over the right hemithorax consistent with increased right pleural effusion. possible worsening mild fluid congestion. increased left retrocardiac opacity consistent with atelectasis/however an aspiration/pneumonia cannot be excluded. . tte: the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. overall left ventricular systolic function is normal (lvef 70%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (area 1.2-1.9cm2). the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. at least moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . ct abd/chest/pelvis: impressions: 1. right inguinal hernia containing small bowel with no current evidence of strangulation. 2. wedge-shaped hypodensity at the left kidney, likely infarct in this patient with history of endocarditis. 3. cholelithiasis 4. left inguinal hernia and umbilical hernia. 5. diverticulosis. 6. dense atherosclerotic calcific disease. 7. bilateral pleural effusions, right lung atelectasis and scattered sub 5-mm pulmonary nodule with no specific followup indicated for the nodules absent, any known malignancy, or neoplastic risk factors. 8. right breast calcifications, comparison with mammography is recommended. . . ekgs: . ekg: atrial fibrillation with rapid ventricular rate 124. non-diagnostic repolarization abnormalities. compared to the previous tracing of cardiac rhythm is now atrial fibrillation with a rapid ventricular rate. . ekg: rate 75, sinus rhythm. occasional premature atrial contractions. probable inferior wall myocardial infarction of indeterminate age. compared to prior the patient is now back in sinus rhythm. q waves in the inferior leads are more prominent. . ekg: rate 147, atrial fibrillation with rapid ventricular response possible prior inferior myocardial infarction but is nondiagnostic left ventricular hypertrophy nonspecific st-t abnormalities since previous tracing of , atrial fibrillation has replaced sinus bradycardia and further st-t wave changes present . . microbiology: . urine culture : final- no growth . blood culture -no growth blood culture -no growth blood culture -no growth . . 1:35 am blood culture staph aureus coag +. aerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. . . 6:55 am blood culture staph aureus coag +. aerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. . 6:00 pm blood culture blood culture, routine (final ): staph aureus coag +. sensitivities performed on culture # 265-0094s . anaerobic bottle gram stain (final ): gram positive cocci in clusters. . 3:20 pm blood culture blood culture, routine (final ): staph aureus coag +. sensitivities performed on culture # , . anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters . . joint fluid: 2:52 pm joint fluid//left shoulder. gram stain: 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): staph aureus coag +. sparse growth. ________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin-------------<=0.25 s trimethoprim/sulfa---- <=0.5 s ............................................................... . 11:00 am blood culture blood culture, routine (final ): staph aureus coag +. sensitivities performed on culture # 265-0094s . anaerobic bottle gram stain (final ): gram positive cocci. in pairs and clusters. brief hospital course: in summary, the patient is a -year-old female who has known history of atrial fibrillation (not anticoagulated due to falls), htn, and breast cancer, who presented after an unwitnessed fall. unfortunately, she went on to have a complicated hospital course which included unstable and refractory atrial fibrillation with rvr, shoulder effusion with +mssa, gpc bacteremia, suspected endocarditis, and dyspnea with hypoxia. despite antibiotics, she had a persistent leukocytosis and septic picture, and declined further after developing an acute small bowel obstruction/ileus with complex inguinal hernias. she was maintained as comfort measures only towards the end of her hospitalization per hcp/family's wishes and she passed away on . additional hospital course details outlined below: . # small bowel obstruction: soon after transfer to cardiology service on the patient was noted to have markedly worse abdominal pains which she had been having for 2 days prior. she reported no bowel movements in 5 days. physical exam revealed severe abdominal pain, rebound tenderness at rlq & llq, diffuse distension. lactate went up to 2.2 and wbc went up to 36 range by . a large right inguinal hernia noted on exam, but was reducible. ct abdomen was done and confirmed sbo and potential incarcerated right inguinal hernia which was at a transition point near terminal ileum. surgery consult called and advised ngt to help reduce distension. team felt patient's surgical options were limited due to her worsening co-morbidities, especially her bacteremia /borderline sepsis, suspected endocarditis, and unstable atrial fibrillation with rvr. patient also expressed she did not want any invasive means. no surgical interventions were pursued and patients status changed to comfort measures only. ngt was removed, and she was given morphine iv and pr tylenol as needed and iv ppi and iv zofran for nausea relief. . #. atrial fibrillation: presented to ed with atrial fibrillation to 140s with rvr. at times atrial fibrillation changed over to atrial flutter and converted back to nsr with rate in 70s after 10 mg boluses of iv diltiazem x2. however, rate very poorly controlled on the medical floor after admission, though she initially responded to diltiazem in ed. she had limited response to po metoprolol, iv diltiazem boluses. tsh was wnl this admission. volume overload and hyperadrenergic state likely contributed to her refractory tachycardia. given age and fall risks she was felt to be a poor candidate for anticoagulation and was not placed on any coumadin, but her asa was increased to 325mg daily dosing. once she was transferred to the micu it appeared that her acute, severe abdominal pain was also exacerbating her atrial fibrillation. this pain continued and sbo diagnosed. unfortunately, as aforementioned, surgery was essentially not an option as she became more unstable and ill later in her hospital course. cardiology consulted after patient transferred back to medical floor from icu and alternative medications for rate and some rhythm control discussed. amiodarone was considered risky in that it could switch quickly back to sinus and promote a cva as she had been in atrial fibrillation, poorly controlled, with little anticoagulation. she was not stable enough for tee either. esmolol was entertained but she had demonstrated that she was very prone to hypotension with prior beta blockade, and had poor response in general thus far to other beta blockers. digoxin was less desireable due to her chf and chance that it would worsen her diastolic function and make her more unstable. thus, the team continued with uptitration of diltiazem drip and metoprolol tartrate 5 mg iv q4h. with this regimen she had a few hypotensive episodes which were short lived, but her rate was a little better controlled to the 115-120 range, but she soon climbed into the 130s again. after she was soon made cmo, telemetry and cardiac medications discontinued per hcp/family's wishes. . #. leukocytosis: she had staphylococcus aureus bacteremia (mssa) and new septic arthritis with mssa as well. her persistent mssa bacteremia at beginning of hospital stay, ongoing tachycardia, poor appetite, & fevers all concerning for endocarditis, though no obvious vegetations seen on tte. she was initially continued on vancomycin and gentamicin per id recommendations, and peaks and troughs were monitored. after some initial culture data returned she was placed on cefazolin and gentamicin, and then when results showed mssa, she was placed on nafcillin 2 g iv q6h therapy. daily surveillance blood cultures collected until she finally cleared around . she had been having high wbc counts to 25-36 at time she transferred to cardiology floor on . initial concern was for possible c.difficile in setting of recent antibiotics and her abdominal pain, however, she reported no bowel movements in days so that was inconsistent with c.difficile. ct abdomen revealed sbo as clear source of her pain. have had elevated leukocytosis from worsening sbo alongside mssa endocarditis. of note, her ct had additional question of pyelonephritis, but repeat ua was unremarkable for infection. lactate rose up to 2.2. she remained afebrile towards end of hospital course but mentation worsened gradually. given eventual cmo status, and family wishes, antibiotics discontinued, and surveillance cultures stopped. . #. hypoxia: she had multiple desaturations after admission and needed to go to icu for fluid overload and was stabilized with iv diuresis, high flow oxygen, and nebulizers. sob was likely from ivfs for arf treatment causing excess congestion from her poorly pumping heart in setting of persistent atrial fibrillation. moreover, additional fluids and her arf secondary to suspected rhabdomyolysis s/p fall probably contributed to a lesser extent. she stabilized from her hypoxia in the icu and was 93-98% on room air on . however, she was still having intermittent desaturations to the low 90s. team titrated up oxygen as needed for comfort with goal sats >92%. she had noted increased accessory muscle use and profound weakness on . at that time family asked she be made cmo, she passed away hours later. . # hypertension: home amlodipine and lisinopril were held in setting of rapid atrial fibrillation and hypotensive tendency. . #. unwitnessed fall: no evidence of pauses on telemetry. no loss of consciousness per patient. neuro exam wnl and no bleeds on ct so a neurological event unlikely. she may have been unstable and lightheaded in the setting of rapid atrial fibrillation with hypotension /poor co, alongside the physiologic bp drop with a concomitant vagal maneuver, as her fall occured while she was on the toilet just after a bowel movement. . #acute renal failure: on admission her cr peaked to 1.5. this was likely secondary to rhabdomyolysis effects after her fall. this is corroborated on labs with +blood and high protein in urine, a cpk of 1585, and potassium elevation on presentation to ed. given ivf hydration and bun/cr trended back to baseline. . #left shoulder pain : orthopedics and rheumatology both offered recommendations and followed the patient. shoulder tap showed no crystals and fluid did not indicate septic joint, but sparse +mssa found on culture. unlikely the main source of her bacteremia. swollen, painful left shoulder. she was given pain control with standing tylenol and breakthrough oxycodone. later, iv morphine given. . #.fluids, electrolytes and nutrition: made npo after sbo discovered, she was given small amounts of ivfs (d51/2 ns) while npo. given history of pulmonary edema no large boluses ordered. initially electrolytes were monitored and repleted daily as needed. once cmo, no longer checked daily electrolytes. . #access: during hospital course she had peripheral ivs, and picc line was placed as well. . #. prophylaxis: she was given sc heparin for dvt prevention and she was continued on iv protonix. at beginning of hospital stay she was given colace/senna for constipation and bowel regimen but this was later discontinued once sbo discovered. . #. code status: the patient was initially maintained as a full code. several conversations took place with palliative care team who helped medical team with this difficult case. ultimately the patient and hcp/family opted to change code status to dnr/dni and shift goals of care to less invasive means with limited procedures or interventions which were felt to offer more risks than benefits as the patient became progressively more ill despite collected efforts from the primary medical, id, surgical, rheumatology, and cardiology services. family asked that patient be shifted to comfort measures only by the last day of her hospitalization, leading up to , when the patient sadly passed away. . medications on admission: home meds: -amlodipine 10 mg daily -asa 81 mg daily -lisinopril 40 mg daily -metoprolol succinate 50 mg daily -zofran 4 mg q6-8hrs:prn ................................. medications on transfer from micu to /cardiology floor on : apap asa 81mg captopril 6.25mg tid diltiazem 300mg xr daily docusate 100mg po bid senna 1 tab po bid heparin sc ipratropium nebulizer lactulose 30mg po tid levothyroxine 100mcg daily metoprolol tartrate 50mg tid milk of magnesia nafcillin 2g iv q6h, day 1= omeprazole 40mg daily ondansetron 4mg iv q8h compazine 10mg iv q6h prn discharge medications: patient expired discharge disposition: expired discharge diagnosis: patient expired discharge condition: patient expired discharge instructions: patient expired followup instructions: patient expired md procedure: venous catheterization, not elsewhere classified arthrocentesis diagnoses: esophageal reflux unspecified essential hypertension acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation personal history of malignant neoplasm of breast atrial flutter acute respiratory failure bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site acute and subacute bacterial endocarditis rhabdomyolysis acute edema of lung, unspecified pyogenic arthritis, shoulder region inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified (not specified as recurrent) 

Answer: The patient is high likely exposed to