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: zosyn attending: chief complaint: right shoulder infection major surgical or invasive procedure: arthroscopy and drainage of right shoulder intubation picc placement history of present illness: mr. is a 63 year old man who was transfered from for surgical evaluation of his right shoulder. per records, he had visited 2 times within the last 2 weeks for right shoulder pain after a fall which was without fracture. he was sent with pain medications and outpatient f/u. he had an mri which was unrevealing (per records). on he was admitted to for increased weakness, fevers, and right shoulder pain. in ed he was noted to have wbc of 16.7 with 54 neuts and 34 bands. he denied n/v, chest pain, sob, abd pain, headache, or syncope. cxr showed no pneumonia. right shoulder was reportedly swollen and erythematous. u/s showed a fluid collection under the deltoid and ortho was consulted. they deferred surgery given his persistent hyponatremia. he continued to spike fevers, developed arf with bun/cr of 51/2.6 (baseline 1.0). he became hypotensive and required levaphed. lfts remained stable and ruq u/s was negative. since it was felt that he needed surgical drainage of his shoulder, he was transfered to . he had 2 peripheral ivs, and was recieving levaphed through them. he arrived on the floor, on max dose of levaphed through his peripheral iv, but was noted to have a pressure of 170s/100s. levaphed was weaned off entirely and the patient remained stable. review of sytems: (+) per hpi (-) denies recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: htn right adrenalectomy mva 20 yrs ago with multiple injuries. significant etoh abuse in past, but per wife, he now drinks only 2 days/wk social history: works as a computer analysist. lives with wife. t - 20 pack year history a - former drinker, but now only drinks socially on fridays/saturdays per wife d - denies illicit drug use, no ivdu family history: nc physical exam: vitals: t: 96.5 bp: 118 p: 108/64 r: 24 o2: 97% on nc of 2l general: alert, orientedx x 1, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachy, reg rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: surgical incision scar, soft, non-tender, moderately distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ edema. r shoulder. very painful with movement skin: diffuse erythematous rash over trunk/chest and arms. pertinent results: labs on admission: 02:44am blood wbc-15.9* rbc-3.26* hgb-9.2* hct-28.9* mcv-89 mch-28.3 mchc-31.9 rdw-16.2* plt ct-293 02:44am blood neuts-76* bands-7* lymphs-5* monos-4 eos-4 baso-1 atyps-0 metas-2* myelos-1* 02:44am blood hypochr-1+ anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 02:44am blood pt-14.5* ptt-24.5 inr(pt)-1.3* 02:44am blood glucose-96 urean-52* creat-2.3* na-131* k-4.9 cl-100 hco3-19* angap-17 02:44am blood albumin-2.3* calcium-8.0* phos-4.0 mg-2.5 02:44am blood alt-82* ast-93* ld(ldh)-320* alkphos-94 totbili-1.0 02:51am blood lipase-31 04:52pm blood lactate-1.1 02:44am blood cortsol-14.4 05:53am blood cortsol-28.5* ecg: baseline artifact. atrial fibrillation or probable atrial flutter with predominantly 2:1 block. the baseline is difficult in terms of making differentiation between atrial flutter and atrial fibrillation and possible st-t wave abnormalities. there certainly is an rsr' pattern in lead v1. clinical correlation is suggested. ct head: there is no hemorrhage, edema, mass effect, or ct evidence of acute large vascular territorial infarction. the -white matter differentiation is preserved. the ventricles and sulci are normal in size and configuration. there is no shift of midline structures. the basilar cisterns are preserved. there are no abnormal extra-axial fluid collections. osseous structures demonstrate no fracture. there is minimal mucosal thickening with small mucus-retention cysts in the right maxillary sinus. the mastoid air cells are normally-pneumatized and clear. there are punctate calcifications in the vertex scalp soft tissues, of uncertain significance. : ct abdomen: 1. no evidence of obstruction or volvulus. 2. small bilateral pleural effusions and bibasilar atelectasis, new since outside hospital ct of . : mri shoulder: 1. complex, enhancing joint effusion with associated loculated collections in the subacromial-subdeltoid bursa and the subscapularis recess. findings are consistent with an inflammatory and/or infectious arthritis. 2. full-thickness supraspinatus and infraspinatus tendon tears with tendon retraction. 3. no definite osteomyelitis. echocardiogram : the left atrium is dilated. the right atrium is dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with probably mild inferior septal hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. : mri/mra of the head: the head mra demonstrates normal flow signal within the arteries of anterior and posterior circulation. distal left vertebral artery ends in posterior- inferior cerebellar artery, a normal variation. : cxr - impression: satisfactory position of the left-sided picc line with the tip in the lower svc. interval improvement in degree of atelectasis in the left lower lobe. mild cardiomegaly with no overt evidence of pulmonary edema. brief hospital course: mr. is a 63 year old male with a history of etoh abuse and hypertension transferred from an osh for septic shock with concern for septic right shoulder. # septic shock/septic shoulder/hap: the patient was transferred from osh on levophed but hypertensive on arrival. levophed weaned off without difficulty. r shoulder suspected source but cell count from initial joint tap by ortho not clearly septic appearing with wbc only 18,000 in setting of traumatic tap with negative culture. given agitation, patient required intubation for mri shoulder. while awaiting that study, lung bases on ct showed pneumonia, presumed hap. levofloxacin was discontinued but patient continued on vanc/zosyn, which was later changed to vanc/meropenem given concern for drug rash. pt subsequently had mri shoulder which showed a complex joint effusion with loculated collections in the subacromial-subdeltoid bursa and the subscapularis recess. r shoulder was re-tapped, this time with 101,500 wbc although still culture negative. pt underwent wash-out of septic right shoulder on requiring extensive debridement and notable for finding of rotator cuff tear; intraarticular and subacromial subdeltoid bursal drains left in place. he underwent joint washout which was uneventful. he completed a course of vancomycin/meropenem for hospital acquired pneumonia and will need to complete a 4 week course of antibiotics for septic shoulder (culture data negative but frank pus in the joint). his vancomycin trough was low at 11.8 on and so his dose was increased to 1.5 grams q12h. his last dose of antibiotics should be unless otherwise decided by his orthopedist. he should follow-up with orthopedics 2 weeks following discharge for suture removal and further discussion regarding his antibiotic course. pain was managed via dilaudid iv in house, patient transitioned to po on discharge. # altered mental status: prior to admission, the patient was last mentally cleared approximately while at osh, prior to initiation of dilaudid and flexeril. concern for head trauma given prior fall, but head ct without acute process. lyme and erhlichia serologies negative. did have history of heavy etoh, but now only drinking 2 of 7 nights per week according to wife. history of illicit drug use prior. likely secondary to polypharmacy given osh dilaudid and short course of stress dose steroids for question of adrenal insufficiency. agitation not responsive to escalating doses of haldol (received 100mg in one day) although some improvement with ativan (despite being out of time frame for etoh withdrawal). required intubation for studies on and controlled on propofol, which was later changed to fentanyl/versed secondary to hypertriglyeridemia. extubated on . patient was also given thiamine, folate, and a mvi. the patient's mental status gradually improved in the unit and the patient felt he was at his baseline the day prior to discharge. oxazepam and neurontin were also held due to concern for ams. these medications were not restarted as the patient appeared to be doing well without them. # tachycardia: atrial flutter vs. atrial fib alternating with sinus rhythm with pacs. tte with biatrial enlargement with mild regional left ventricular systolic dysfunction (ef 45-50%) with probable mild inferior septal hypokinesis. on hctz/bisprolol at home. on required diltiazem drip and high dose metoprolol for rate control and subsequently spontaneously converted to sinus rhythm. he was placed back onto metoprolol for blood pressure and rate control. also started on heparin drip as a bridge to coumadin. patient was discharge on home bisoprolol 20mg daily. # transaminitis: no pain on palpation and ruq u/s from osh without evidence of cholecystitis. lyme and ehrlichia serologies negative. have been secondary to etoh use. improved on discharge. # hypertension: on hctz/bisprolol 10/6.25 , clonidine 0.6 mg qsun, and avapro 300 mg daily as outpatient. clonidine was initially held given mental status. he was restarted on a beta blocker in the unit initially for rate control, then uptitrated in setting of hypertension. losartan was started as avapro is not on formulary. the patient was noted to be markedly hypertensive on transfer to the medical floor. hctz and clonidine patches were restarted on . on discharge the patient was transitioned to home bisoprolol 20mg daily and avapro 300mg daily. # rash: concern for drug rash secondary to penicillins although no documented history of drug allergies. zosyn changed to meropenem with improvement. # anemia: stable. hematocrit was serially monitored. # s/p adrenalectomy: initially presented with shock, hyponatremia, and hyperkalemia. stim was normal so stress dose steroids were discontinued. # acute renal failure: cr down to 1.0 from peak of 3.1 at osh on with improved uop. fena 0.8 suggested prerenal etiology. cr trended back down to normal over hospital course. # constipation: kub concerning for cecal volvulus but not seen on ct abdomen. started on aggressive bowel regimen with good subsequent stool output. # hyponatremia: na 131 on admission, thought secondary to dehydration. corrected without intervention. medications on admission: medications home: asa 325 daily hctz/bisprolol 10/6.25 clonidine 0.6 mg qsun avapro 300 mg daily prilosec 20 mg daily oxazepam q 6hr prn anxiety ambien 5 mg hs neurontin paroxitine 20mg daily discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain. 3. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 4. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for pruritis. 5. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 6. ambien 5 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). 9. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 10. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. 11. clonidine 0.3 mg/24 hr patch weekly sig: two (2) patch weekly transdermal qfri. 12. sodium chloride 0.9 % 0.9 % syringe sig: one (1) 3 ml flush injection q8h (every 8 hours) as needed for line flush. 13. 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. 14. ondansetron 4 mg iv q8h:prn nausea 15. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 16. heparin, porcine (pf) 1,000 unit/ml solution sig: as directed injection continuous iv infusion: based on weight-based heparin dosing plan. 17. vancomycin 750 mg recon soln sig: two (2) intravenous every twelve (12) hours for 4 weeks: needs trough checked on morning of with goal range of 15-20. . 18. avapro 300 mg tablet sig: one (1) tablet po once a day. 19. bisoprolol fumarate 10 mg tablet sig: two (2) tablet po once a day. 20. dilaudid 2 mg tablet sig: (two-three) tablets po q3h as needed for pain. discharge disposition: extended care facility: discharge diagnosis: primary diagnoses: septic arthritis (right shoulder) atrial fibrillation hospital acquired pneumonia altered mental status secondary diagnoses: hypertension anemia acute renal failure discharge condition: vital signs stable. symptoms improved. discharge instructions: you were transferred to from an outside hospital. you were found to have pneumonia, and you completed a course of antibiotics for the pneumonia. you also had an infection in your right shoulder, which was drained and washed out by the orthopedic surgeons. you will need to continue taking intravenous antibiotics for 4 weeks. . you were also found to have atrial fibrillation, which is an abnormal rhythm of the heart. you were started on coumadin, which is a blood thinner, since atrial fibrillation increases your risk of having clots. you should follow-up with a cardiologist as an outpatient to assess the need for life-long anticoagulation. . the following changes were made to your medications: 1. restart your avapro and bisoprolol. you were continued on hydrochlorothiazide. 2. you were started on the blood thinning medication coumadin. you will need to have frequent inr checks until you are stable on this mediation. you will need to continue the heparin drip until your inr has become therapeutic. 3. your oxazepam and neurontin were stopped. you seemed to do okay without these medications. please talk with your pcp to determine if they are necessary. . please call your physician or return to the hospital if you develop high fevers, worsening shoulder pain, chest pain, shortness of breath, or other concerning symptoms. followup instructions: please follow-up at your primary care office on friday @ 9am. please ask your primary care physician to refer you to a cardiologist to discuss how long you should be on anticoagulation. also discuss with them the need to restart your oxazepam and neurontin please call to schedule a follow-up appointment with to have the sutures in your shoulder removed and to follow-up after your shoulder surgery. 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 other local excision or destruction of lesion of joint, shoulder diagnoses: pneumonia, organism unspecified hyperpotassemia anemia, unspecified unspecified pleural effusion unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia hyposmolality and/or hyponatremia severe sepsis atrial fibrillation atrial flutter pulmonary collapse septic shock other constipation alcohol abuse, continuous pyogenic arthritis, shoulder region complete rupture of rotator cuff nontraumatic rupture of tendons of biceps (long head) 

Answer: The patient is high likely exposed to