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: penicillins / haldol / compazine / desipramine / chlorpromazine / imipramine / zoloft / shellfish derived attending: chief complaint: chest pain major surgical or invasive procedure: picc line placement under ir guidance transesophageal echocardiography intubation x 2 history of present illness: hpi: 28f morbidly obese female with h/o of dvt/pe on coumadin presenting with chest pain. pt states that the pain began day before yesterday. she describes it as the same pain as his pe but worse. states that the pain came on suddenly has been constant and severe, a . she states that the pain radiates to both arms, her neck and her lungs. she describes it as a sharp pain. pt also notes that she feels wheezy. she last took her advair yesterday morning and she said that it did not help. prior to admission she has been in radius rehab for 3 days and before that at for 5 days for mrsa bacteremia. in the ed, 99.9 123 145/88 22 93% ra. pt received sl ntg x3 and 4mg iv morphine x2 and iv dilaudid x1, and was started on heparin gtt. d-dimer negative, first set of cardiac enzymes negative, and cta negative for pe but suboptimal study. ekg showed sinus tach with subtle changes in v3 and v4. review of outside hospital records revealed: ms. has experienced multiple admissions to caritas , , hospital and . what follows below is my best attempt at a summary of the data from discharge summaries and cultures received from the various institutions. segments of this information will be repeated in her discharge summary. - admitted to caritas for dyspnea no abx/bcx reported admitted to caritas for picc related bacteremia. no indication of when picc was placed initially. "power picc" placed on discharge for vanc therapy 1g q12 to end wound cx: light skin flora wound cx: skin flora mrsa screen "present" ucx: >100,000 cfu/ml mixed perineal flora bcx: ngtd bcx: staph epidermidis: : levoflox, tetra, vanc, dapto, rif ucx: & mixed perineal flora bcx: ngtd bcx: staph hominis: : levoflox, tetra, vanc, dapto, rif bcx: ngtd bcx: ngtd : admitted to caritas for chest pain ruled to be dvt of r subclavian, brachial veins & pe. no mention of vanc or picc line. : admitted for chest pain, pe "improved" on cta from prior admission. rue picc line mentioned in pcp : mrsa screen neg : vre present : bcx: ngtd : admitted to caritas for rue with mrsa picc bacteremia. : staph hemo: : clinda, linezolid, tet, vanc, dap, rif mrsa: : linezolid, tet, vanc, dap, rif : bcx: staph h & mrsa : levoflox, tetra, vanc, dapto, rif : bcx: staph h & mrsa : levoflox, tetra, vanc, dapto, rif : picc cx: mrsa & staph hemo : admitted to for chest pain ruled to be costochondritis after no ekg changes or enzymes changes from (reports not available) no culture data transferred to : transferred to at patients request for chestpain & port placement? picc removed and replaced for vancomycin 1g iv bid to end on , at various points in the chart. all records available on chart in "osh records" : bcx: coag negative staph: : levoflox, tetra, vanc, dapto, rif past medical history: bipolar disorder copd - asthma obesity depression suicidal ideation and multiple attempts in the past on mrsa cellulitis pna bacteremia urinary incontinence pe/dvts self-mutilation social history: only child, raised by iv drug addict, physically abusive parents until age 8 when taken into dss custody. states she was "mad at the world" and set fires. was psychiatrically hospitalized and grew up between homes, residential facilities, and inpatient psychiatric hospitals. remained institutionalized in various settings including years in intermediate care at . one year ago, tried it on her own and describes struggling since being outside of a group home or other institutionalized setting. of note, anniversary of mother's death is and anniversary of father's death is . she generally psychiatrically decompensates and becomes suicidal on these dates. family history: parents deceased; otherwise noncontributory physical exam: vitals 99.0 124/69 88 22 95%ra gen: morbidly obese, hirsutism, nad heent: nc, at, mmm, eomi neck: obese, unable to assess jvp resp: difficult to assess breath sounds body habitus, + wheezes, otherwise clear cv: difficult to assess body habitus, rrr. abd: soft, diffusely mildly tender, obese, bs+ ext: no edema, wwp skin: candidal rash in right groin pertinent results: admission labs: 09:55pm blood wbc-15.3*# rbc-4.18* hgb-11.9* hct-37.5 mcv-90# mch-28.4 mchc-31.7 rdw-16.0* plt ct-439 09:55pm blood neuts-90.8* lymphs-7.6* monos-1.2* eos-0.3 baso-0.1 09:55pm blood pt-18.9* ptt-18.6* inr(pt)-1.7* 09:55pm blood d-dimer-237 09:55pm blood glucose-217* urean-15 creat-0.8 na-140 k-4.9 cl-97 hco3-35* 09:55pm blood ck(cpk)-29 06:50am blood alt-7 ast-8 ld(ldh)-173 ck(cpk)-16* alkphos-59 amylase-33 totbili-0.1 06:50am blood lipase-19 09:55pm blood ctropnt-<0.01 06:50am blood ck-mb-notdone ctropnt-<0.01 06:52pm blood ck-mb-notdone ctropnt-<0.01 06:50am blood albumin-3.3* calcium-9.2 phos-4.5 mg-2.3 cholest-213* 06:50am blood %hba1c-6.5* 06:50am blood triglyc-202* hdl-84 chol/hd-2.5 ldlcalc-89 08:59am blood prolact-78* 06:50am blood crp-25.8* 08:59am blood lithium-0.5 valproa-34* 03:27pm blood lithium-0.3* valproa-94 gram stain (final ): no polymorphonuclear leukocytes seen. 2+ (1-5 per 1000x field): gram positive cocci. in pairs. fluid culture (final ): staphylococcus, coagulase negative. moderate growth. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. staphylococcus, coagulase negative. moderate growth. second strain. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- 4 r =>8 r oxacillin------------- =>4 r =>4 r penicillin g---------- 0.25 r =>0.5 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- <=1 s <=1 s vancomycin------------ 2 s <=1 s clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. discharge labs: 03:44am blood wbc-5.5 rbc-3.01* hgb-8.4* hct-26.4* mcv-88 mch-28.0 mchc-31.9 rdw-16.6* plt ct-363 03:44am blood pt-32.3* ptt-31.4 inr(pt)-3.4* 03:44am blood glucose-112* urean-7 creat-0.5 na-145 k-3.5 cl-101 hco3-36* angap-12 03:44am blood calcium-8.3* phos-3.4 mg-1.8 09:50pm blood type-art fio2-40 po2-84* pco2-62* ph-7.40 caltco2-40* base xs-10 intubat-intubated 11:19am urine color-yellow appear-clear sp -1.014 11:19am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-negtee : no valvular disease studies: ekg: sinus rhythm. normal tracing. compared to the previous tracing the rate is slower. cta chest - impression: 1. no central or segmental pulmonary embolism. 2. no aortic dissection. tte - the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is dilated but function appears preserved. the aortic valve leaflets appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. technically suboptimal to exclude focal wall motion abnormality. moderate pulmonary hypertension. no obvious valvular vegetations seen but technically suboptimal to exclude endocarditis. if clinically indicated, a tee would better assess for vegetations. abdominal ultrasound - impression: 1. markedly limited study due to patient body habitus. 2. fatty infiltration of the liver, fibrosis, and/or cirrhosis, with no focal liver lesions. 3. no explanation for abdominal pain. 4. ill-defined density in the upper third of the right kidney, for which further imaging is recommended. ct abdomen & pelvis with contrast - impression: no acute intra-abdominal pathology to explain patient's chest pain. tee - the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. a small color doppler signal (#50) is seen c/w a small secundum type atrial septal defect with left-to-right shunt flow. overall left ventricular systolic function is normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. impression: no valvular pathology identified. small secundum type atrial septal defect. right hand x-rays: impression: no acute fracture or dislocation. slight osseous prominence at fourth digit proximal phalanx may be the sequelae of old trauma. ct abdomen & pelvis without contrast - impression: 1. no evidence of retroperitoneal hemorrhage. 2. mild, focal, ascending colon bowel wall thickening and peri-colonic fat stranding consistent with colitis. differential includes infectious or inflammatory causes; correlation with antibiotic history would also be helpful. right hand x-ray - there are no signs for acute fractures or dislocation. some slight flexion deformity of the right fourth dip joint, however no acute fractures identified. there is a prominence of soft tissues due to the patient's body habitus. ct head without contrast - impression: no acute intracranial pathology including no hemorrhage. eeg - findings: abnormality #1: throughout the recording the background rhythm was a hz rapid pattern with an anterior predominance but generalized distribution. abnormality #2: there were frequent bursts of generalized delta slowing. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular rhythm. impression: abnormal portable eeg due to the widespread, relatively uniform alpha-beta frequencies in the background and due to the bursts of generalized slowing. these findings suggest a widespread encephalopathy. the faster frequencies seen without the usual posterior predominance are very suggestive of medication effect. there were no areas of prominent focal slowing, and there were no epileptiform features. brief hospital course: 28 year old morbidly obese lady with psychiatric & medical problems presenting with chest pain of indeterminate etiology and recent bacteremia. pe and ischemia were ruled out as causes of her chest pain, however, her hospital course was complicated by an episode of hypercarbic respiratory failure and an episode of respiratory alkalemia, both requiring intubation. chest pain: the patient complained of chest pain throughout her hospital stay. a thorough history and physical exam, ekg, cardiac enzymes, echocardiogaphy (tte & tee), breast discharge cultures, blood cultures, chest x-rays, ct scan, abdominal ultrasound and ct failed to discover an organic etiology of her pain. her pain was relieved temporarily on morphine & acetaminophen, but the patient declined these medications. a comprehensive review of outside hospital records from , caritas , caritas , and indicated that the patient has chronically complained of unexplained chest pain in the past 6 months. given her history of upper extremity dvts we maintained her on a heparin drip until her inr returned to the therapeutic range. no evidence of dvt was found via d-dimer or on ct scan. we were unable to conclusively diagnose or medically treat her pain on this admission. bacteremia: the patient was admitted with a l picc line in place for vancomycin therapy for mrsa bacteremia from per her report. her picc line could not verified on cxr, so it was removed, tip cultured and replaced under ir guidance. outside records from several hospitals were obtained indicating a recent history of picc line infections resulting in bacteremia. her blood cultures remained negative while admitted. infectious disease was consulted and recommended tee to exclude endocarditis. upon exclusion of endocarditis, the patient was continued on vancomycin until and the patient's picc line was removed. history of pe: the patient has a history of upper extremity dvts leading to pe. she was continued on heparin while her inr became therapeutic between . negative d-dimer and cta excluded pe at this time. bipolar disorder/borderline personality disorder: psychiatry was consulted to assist in the managment of the patient's psychiatric medication. through communications with her outside psychiatrist, it was determined that the patient would be tapered off of lithium given her polyuria/incontinence. in addition, while evaluating a scant breast discharge, it was discovered that the patient was hyperprolactinemic. her risperdal was stopped and she was converted to abilify. asthma: the patient had a history of asthma. she had received one dose of prednisone taper from before admission to . this was not continued given her recent bacteremia. she was maintained on advair & atrovent as needed. her respiratory status remained stable. r 4th digit dislocation: patient dislocated 4th digit when trying to sit up in bed. a hand x-ray confirmed dislocation. patient was seen by plastic surgery who reduced and splinted her with an ulnar gutter splint. the cast should stay on until the patient sees them for follow-up in hand clinic two weeks after the splint was placed. she has an appointment scheduled with them. micu course: the patient was transfered to the micu on after becoming hypoxic, acidotic, and hypercarbic in the setting of being more somnolent after refusing cpap at night. a respiratory code was called and she was intubated on the floor and brought to the icu. she was extubated on . she maintained good o2 sats throughout the night of while wearing cpap, but desatted the following morning to the mid 70s when refusing to wear her cpap. she was called out the floor the evening of , but returned to the icu after becoming agitated and refusing to use cpap at night. the patient was placed on 2l nc with pulse oximetry monitoring. she maintained o2 sats in the mid to upper 80s for most of the night, but desatted to the low 70s again and cpap was placed on her face while she continued sleeping. she maintained o2 sats in the low to mid 90s while on cpap. on the evening of the patient was nonresponsive to sternal rub despite o2 sats >98% and being on cpap. her eyes were deviated downward and an abg revealed a respiratory alkalosis. the patient was reintubated and her blood gases normalized. she had a head ct that showed no intranial bleeding or acute abnormality. the following day she was extubated and had an eeg, given concern for seizure activity. no epileptiform activity was noted on eeg. neurology was consulted and felt that the patient had not had a seizure, though she did have some clonus on exam. ultimately, it was felt that this episode of unresponsiveness may have been medication related, though seizure could not be definitively excluded. to maintain her oxygen saturation and prevent hypercarbia, the patient must wear bipap or cpap mask while sleeping. she intermittantly refused this and had to be continually encouraged to wear it. her settings on discharge with a nasal bipap mask were inspiratory pressure 16, expiratory pressure 6 with 12 l o2 to keep o2 sats >88%. throughout her micu stay, psychiatry continued to follow the patient in consultation to assist with adjusting her psychiatric medications and guiding the psychosocial aspects of her care. given her two incidents of unresponsiveness (one hypercarbic and the other respiratory alkalosis) they recommended decreasing her abilify from 20 mg to 15 mg on discharge. they also recommended crushing her medications and doing mouth checks given the patient's history of stockpiling medications and a lingering question of whether taking extra medications may have contributed to one or more of her epidoes of unresponsiveness. the patient has had a number of different outpatient psychiatrists involved in her care and it has been awhile since she has seen dr. (). she would benefit from having a single provider following her care. medications on admission: albuterol q4h prn colace senokot mvi oscal mg daily nexium 40mg daily ditropan 5mg tid atrovent neb q4h prn advair 500/50 depakote 2000mg qhs risperdal 3mg qhs celexa 60mg daily per rehab (80mg per pt) lithium 450mg tid coumadin prednisone - one time dose 50mg at 9am vancomycin 1gm at 1400 coumadin 5mg daily discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. multivitamin tablet sig: one (1) tablet po daily (daily). 4. tolterodine 1 mg tablet sig: one (1) tablet po bid (2 times a day). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 8. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 9. ropinirole 1 mg tablet sig: 1.5 tablets po qpm (once a day (in the evening)). 10. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 12. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 13. citalopram 20 mg tablet sig: three (3) tablet po daily (daily). 14. aripiprazole 10 mg tablet sig: one (1) tablet po daily (daily) as needed for agitation. 15. aripiprazole 15 mg tablet sig: one (1) tablet po once a day. 16. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 17. zolpidem 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 18. miconazole nitrate 2 % cream sig: one (1) appl vaginal hs (at bedtime) for 5 days. 19. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed. 20. valproic acid 250 mg capsule sig: four (4) capsule po q12h (every 12 hours). 21. albuterol 90 mcg/actuation aerosol sig: inhalation every 4-6 hours as needed for shortness of breath or wheezing. 22. warfarin 2 mg tablet sig: one (1) tablet po once a day: please hold on and monitor inr before resuming this medication. discharge disposition: extended care discharge diagnosis: primary diagnoses: 1) bipolar disorder 2) borderline personality disorder 3) mrsa bacteremia 4) hypercarbic respiratory failure 5) respiratory alkalosis 6) right phalangeal dislocation, s/p reduction & splinting secondary diagnoses: 1) hyperprolactinemia 2) hypertension 3) history of dvts discharge condition: stable, maintains o2 sats >88% on room air while awake, requires supplemental o2 by bipap or cpap while sleeping. intermittantly refuses medication, labs, and o2 therapy. discharge instructions: you have been admitted to the hospital with chest pain and for a blood infection. we performed extensive testing but were unable to determine a cause for your chest pain. while you were here, we continued your treatment for a blood bacterial infection and determined that it did not enter your heart. your infection cleared and antibiotics were stopped. you were transfered to the icu for an episode of unresponsiveness due to too much co2 in your blood. you need to wear a cpap or bipap mask while you sleep to prevent this from occuring again. please take your medications as prescribed. please call your doctor for any concerning medical symptoms. followup instructions: please attend the following appointments regarding your right hand splint and plan to arrive at the building, at 8:10 am on . provider: xray (scc 2) phone: date/time: 8:10 provider: clinic phone: date/time: 8:30 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified insertion of endotracheal tube application of splint closed reduction of dislocation of hand and finger diagnoses: unspecified septicemia severe sepsis acute respiratory failure alkalosis morbid obesity long-term (current) use of anticoagulants other chest pain personal history of venous thrombosis and embolism unspecified accident other and unspecified infection due to central venous catheter bipolar disorder, unspecified methicillin resistant staphylococcus aureus septicemia closed dislocation of finger, unspecified part 

Answer: The patient is high likely exposed to