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: morphine / dilaudid attending: chief complaint: right knee pain major surgical or invasive procedure: right knee revision central line placement picc placement history of present illness: 64 year old female with history of pud, crohn's, cad s/p stent, chf, ra and recent admission to micu for hypotension and acute renal failure who presented to clinic yesterday for follow up complaining of right knee pain which had worsened over the past two days. knee was not hot or erythematous and plan was for ortho follow up within the next 1-2 days. pt also reported myalgias and fatigue. creatinine was checked as follow up from d/c. labs checked noted cr 3.8 (from 1.4 on ), hco3 18, hct 33, wbc 14.2, k 5.3. of note, pt was recently admitted for c/o r.leg heaviness, ?slurred speech on . code stroke was called and imaging showed "small infarct in l.ic of uncertain chronicity. however, this was not thought to be due to acute infarct. mild ath dx in prox left ica. renal failure resolved with hydration. hypotension resolved by holding anti-hypertensives. pt also presented with r.sided back/leg pain which was attributed to radiculopathy. in ed, patient complaining of on-off substernal chest pain since yesterday evening. also diffuse myalgias. t was found to be 102.3 rectally. lactate wnl. ct abd, central access obtained. t 102.3 rectal. pt given doses of vanc/zosyn/flagyl. ortho tapped r.knee and jfa was c/w septic joint. pt found to be hypotensive, given 3l ivf and started on levophed. upon arrival to the floor: pt states that since discharge, her legs have felt "weak" and she has had pain in her r.leg. she otherwise denies fevers/chills, sob/cp, abd pain/n/v/d/c/melena/brbpr, dysuria/hematuria, or joint pain other than her r.leg/knee. past medical history: past medical history (per notes,confirmed with pt): 1. cad s/p rca w/bms on 2. diastolic chf (recent ef~55%) 3. crohn's disease: h/o pancolitis w/o small bowel involvement; colonoscopy showed no active disease 4. chronic renal failure (cr~1.4 at baseline). 5. dm type ii 6. hypertension 7. h/o idiopathic dilated cmp now resolved 8. peptic ulcer disease. 9. alcoholic cirrhosis. 10. gerd. 11. rheumatoid arthritis. 12. pulmonary embolus in . 13. total right knee replacement with subsequent chronic pain. 14. mal seizure in childhood. 15. cervical disc disease. 16. l5/s1 radiculopathy with anterolisthesis of l4 on l5 on x- ray with emg consistent with mild radiculopathy. 17. recent gib in of unclear etiology . surgery: r knee replacement surgery per ortho notes:rtkr ' () complicated by septic arthritis s/p irrigation and debridement, arthrotomy, revision of liner with scorpio #5, 10 mm thickness liner in ' (krod) social history: patient lives with a disabled son in . she has one other son who is currently incarcerated. she was married but divorced a long time ago. quit smoking 10 years ago. drank ~1 pint alcohol/day x 10 years, quit 10 yrs ago. no illicit drugs. family history: mom died of cancer. father with dm requiring bilateral below the knee amputation. one sister has had cervical cancer(cured) and rheumatoid arthritis. most members of her family have trouble with hypertension. no one else with ibd. grandmother with cancer. physical exam: vitals: t. 98.0, bp 114/85, hr 92, rr 17, sat 100% ra on 0.043 levo gen: obese female, nad, somnolent but arousable to answer questions. heent: perrla, eomi, anicteric, mmm neck: hard to access for jvd body habitus, no lad chest: b/l ae no audible w/c/r heart: s1s2 rrr no m/r/g abd: +bs, obese, soft, nt,nd ext: r.leg/knee >l.leg, +mild erythema, +old healed surgical scar, ttp, otherwise 2+pulses. neuro:somnolent, but aaox3 pertinent results: laboratory: 05:55am blood wbc-9.7 rbc-2.97* hgb-8.4* hct-25.6* mcv-86 mch-28.4 mchc-32.9 rdw-16.6* plt ct-372 05:25pm blood wbc-14.2* rbc-3.62* hgb-10.7* hct-33.3* mcv-92 mch-29.7 mchc-32.2 rdw-14.8 plt ct-360 01:00pm blood pt-13.4 ptt-29.3 inr(pt)-1.1 02:58am blood d-dimer-2605* 05:55am blood glucose-91 urean-12 creat-1.3* na-139 k-4.1 cl-110* hco3-20* angap-13 05:25pm blood urean-36* creat-3.8*# na-133 k-5.3* cl-102 hco3-18* angap-18 11:00pm blood alt-16 ast-25 ld(ldh)-185 alkphos-114 amylase-113* totbili-0.6 11:00pm blood lipase-41 06:10am blood ck-mb-10 mb indx-1.4 ctropnt-0.03* 08:20pm blood ctropnt-0.04* 08:20pm blood ck-mb-12* mb indx-1.5 01:00pm blood ctropnt-0.04* 01:00pm blood ck-mb-18* mb indx-1.9 05:55am blood calcium-8.5 phos-4.4 mg-1.8 11:00pm blood albumin-3.2* calcium-8.0* phos-4.7*# mg-1.6 03:08am blood vitb12-393 03:08am blood tsh-2.1 05:25pm blood tsh-5.4* 12:00pm blood cortsol-32.3* 11:30am blood cortsol-30.1* 10:50am blood cortsol-24.5* 06:10am blood rheufac-20* crp-251.5* 04:24pm blood crp-198.7* 11:00pm blood asa-neg ethanol-neg acetmnp-5.1 bnzodzp-neg barbitr-neg tricycl-neg 01:53pm urine color-straw appear-clear sp -1.008 01:53pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 01:53pm urine rbc-0-2 wbc-0-2 bacteri-none yeast-none epi-0 01:53pm urine hours-random urean-206 creat-29 na-141 02:27am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg 05:15pm joint fluid wbc-* rbc-4500* polys-97* lymphs-1 monos-0 macro-2 05:15pm joint fluid crystal-none 05:15pm joint fluid totprot-4.2 glucose-62 ld(ldh)-1338 microbiology: 3:05 pm urine site: clean catch urine culture (final ): no growth. 1:00 pm blood culture #1. blood culture, routine (final ): no growth. 5:15 pm joint fluid **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): specimen not transported anaerobically. anaerobic culture not performed. test cancelled, patient credited. reported by phone to dr () at 3:40pm. 5:28 am serology/blood rapid plasma reagin test (final ): nonreactive. 8:40 am foreign body right knee. wound culture (final ): no growth. tissue site: knee gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (preliminary): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): fungal culture (preliminary): no fungus isolated. potassium hydroxide preparation (final ): no fungal elements seen. 10:15 pm blood culture blood culture, routine (pending): diagnostics: ct abdomen/pelvis: ct abdomen: evaluation is limited by lack of intravenous contrast, small amount of oral contrast, and streak artifact from the patient's hands, which are overlying her midabdomen. moderate dependent bibasilar atelectasis, and coronary artery calcifications are unchanged. liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys remain grossly unremarkable. there is no hydronephrosis. stomach and intra- abdominal loops of bowel are unremarkable. there is no sign of bowel obstruction, or fluid collection to suggest abscess formation. there is no free air, free fluid, or abnormal intra-abdominal lymphadenopathy. note is made of small injection granulomas in the anterior lower abdominal wall, some of which contain small foci of air. ct pelvis: pelvic loops of large and small bowel, and genitourinary structures remain normal. foley catheter balloon is seen within decompressed bladder. there is no free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy. osseous structures: no suspicious lesions are present. impression: no acute intra-abdominal pathology. no significant change since . right knee xray: impression: small effusion. no evidence of loosening or acute fracture. cxr: single frontal view of the chest: lung volumes are low. the cardiomediastinal silhouette is stable. a new right subclavian catheter is present with tip terminating over the lower svc. there is no pneumothorax. mri c-t-lspine: findings: there are degenerative changes seen in the cervical region with posterior ridging from c3-4 to c5-6 level. there is no spinal stenosis or extrinsic spinal cord compression seen. at c6-7, mild degenerative changes noted. small bilateral perineural cysts are visualized within the neural foramina. there is no evidence of discitis or osteomyelitis in the cervical region. subtle increased signal is identified between the spinous processes of c5 and c6 of unclear etiology and could be degenerative in nature. note is made of increased signal of scalenus medius and posterior muscles bilaterally at the level of c7-t1 which could indicate focal inflammation of the muscles. further evaluation can be obtained with brachial plexus mri if clinically indicated. impression: 1. degenerative changes in the cervical spine without spinal stenosis or spinal cord compression. 2. increased signal within bilateral scalene muscles at c7-t1 level could be due to focal muscular inflammation. however, for better evaluation, brachial plexus mri can help if clinically indicated. no evidence of discitis or osteomyelitis. thoracic spine: technique: t1, t2 and inversion recovery sagittal images of the thoracic spine were acquired. findings: mild multilevel degenerative changes are seen. no evidence of spinal cord compression seen. no evidence of marrow edema or compression fracture noted. impression: mild degenerative changes. no evidence of spinal cord compression, discitis or osteomyelitis. lumbar spine: technique: t1, t2 and inversion recovery sagittal and t2 axial images of the lumbar spine were acquired. findings: at l1-2, no abnormalities are seen. from l2-3 and l3-4, mild degenerative disc disease is seen. at l4-5, there is widening of facet joints noted with fluid within the facet joints secondary to degenerative change. there is mild spinal stenosis and moderate bilateral subarticular recess narrowing seen. there is mild right foraminal narrowing seen. there is a disc protrusion in the left foramen, which appears to be deforming the exiting left l4 nerve root. at l5-s1 level, degenerative disc disease and mild bulging seen. the distal spinal cord shows normal signal intensities. the paraspinal muscles are unremarkable. there is increased signal identified in the subcutaneous fat in the upper lumbar region, which could be due to mild edema. no definite fluid collection is seen. impression: 1. severe left foraminal narrowing at l4-5 level due to disc protrusion and facet degenerative changes which could result in irritation of left l4 nerve root. mild spinal stenosis and moderate bilateral subarticular recess narrowing is also seen at l4-5 level. 2. mild multilevel degenerative changes at other levels. 3. no evidence of bony metastasis or high-grade thecal sac compression. no evidence of discitis or osteomyelitis. echo: the left atrium and right atrium are normal in cavity size. 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. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: no vegetation or abscess seen. normal regional and global biventricular systolic function. trace aortic and mitral regurgitation. ct head: conclusion: no change since . there is no evidence of hemorrhage or recent infarction. cta chest: impression: 1. no evidence of pulmonary embolism. 2. coronary artery calcifications. ecg: sinus tachycardia. old inferior myocardial infarction. poor r wave progression across the anterior precordial leads. consider prior anteroseptal myocardial infarction. compared to the previous tracing of poor r wave progression is seen across the precordial leads and the other findings are similar. : right knee, three views there is a large amount of methyl methacrylate in the distal femur and proximal tibia. there is increased soft tissue density anterior to the knee joint. the patella abuts the anterior surface of the methyl methacrylate. a small locule of air is seen anterior to the distal femur and medial to the knee joint. overlying skin staples are present. relative lucency in the distal femur anteriorly likely reflects the former site of the femoral prosthesis. allowing for background osteopenia and post-operative changes, no definite evidence of osteomyelitis is identified. brief hospital course: a/p: pt is a 64 y.o female with mmp including cad, chf, dm, ckd3, htn, etoh cirrhosis, h.o pe, s/p r.tkr who presents with r.septic knee, , and hypotension. #. sepsis secondary septic r knee: patient was admitted with fever, leukocytosis, hypotension (requiring ivf resuscitation and levophed for less than 24 hrs), and source of infection as septic r knee (positive tap in ed), s/p instrumentation in the past. she has signs of organ dysfunction, mainly arf. pt was started on vanco/zosyn. ortho was consulted and took the patient to the or for total knee revision on . her instrumentation was removed and a temporary replacement was placed. the arthroplasty was sent for culture, which had no grown. tissue from the surgery also had no growth, but all knee cultures were sent after recieving antibiotics. she had a tte that did not visualize any vegetations though it was suboptimal. she also had an mri of her entire spine to eval for other nidus of infection/abscess given bue and rle pain/weakness. the mri showed no evidence of abscess, diskitis, or osteomyelitis. she was continued on vancomycin and ceftriaxone which she will continue for 6 weeks until she sees dr. in infectious disease clinic on . she will need weekly cbc with diff, chem 7, lfts, esr, crp, and vanco trough levels faxed to infectious disease fax #. the patient will followup in clinic on for staple removal. she will have the hardware replaced in 6 weeks with orthopedics. # hypotension: this was likely secondary to sepsis secondary to infected r knee joint and this was treated as above. she had a cortisol stimulation that was normal. she was not given steroids. her antihypertensives were initially held, but restarted prior to discharge. #acute kidney injury on ckd 3: pt's baseline cr is 1.3-1.6, and she presented this admission with cr 3.4. last admission she had also presented with cr 3.4 that resolved to 1.4 after ivf. her ckd is likely secondary to htn/dm. acute on chronic renal failure likely secondary to hypovolemia (pt given 3l in ed) plus septic physiology. at the time of discharge, her creatinine was back to her baseline of 1.3. # cardiac: 1. cad: pt has h.o bms to rca in . pt had presented with chest pressure that lasted a few minutes. ekg showed no acute ischemic changes. she was ruled out for mi by ces x3. asa/plavix were initially held given or plans. bb, were initially held for hypotension. prior to discharge, she was restarted on her cardiac meds. 2. history of chronic diastolic chf/cmp: she was initially volume resuscitated. she is followed by dr. in heart failure clinic. she will be discharged on her metoprolol succinate, diovan, and her statin as was previously prescribed. her lasix is to be used every other day as needed for weight greater than 195 lbs. # dm: pt was continued on lantus, hiss. her glucose remained in the 100s with her lantus not requiring sliding scale insulin. # pancreatic insufficiency: pt was continued on creon tid with meals. # crohn's disease: the patient is on asacol as an outpatient. she is also on ciprofloxacin 250 mg chronically. during her hospitalization, ciprofloxacin was stopped since the patient is already on ceftriaxone. her ciprofloxacin will be held until she completes her course of ceftriaxone, and dr. in clinic will discuss with the patient's gastroenterologist whether this medication should be restarted. # chronic neuropathic/radicular pain: home long-acting narcotics were initially held given her somnolence. she was continued on topimax, gabapentin, duloxetine. at the time of discharge, she was restarted on her oxycontin at a lower dose of 20 mg tid with oxycodone 5 mg for breakthrough pain. she is also on standing acetaminophen. her oxycontin can be uptitrated to 40 mg tid as an outpatient if needed. initially, due to her mental status changes, it was thought that this was likely secondary to narcotics, especially post operatively. a head ct did not show any evidence of hemorrhage. it was felt that the likely cause of her altered mental status was the hydromorphone and her sepsis. hydromorphone has been added to her allergy list. # h/o tia symptoms: neurology was not convinced presentation was consistent with acute stroke during last admission. she is on asa/plavix for secondary prevention. the crohns disease and pancreatic insufficieny were stable. she is also on ciprofloxacin 250 mg chronically. during her hospitalization, ciprofloxacin was stopped since the patient is already on ceftriaxone. her ciprofloxacin will be held until she completes her course of ceftriaxone, and dr. in clinic will discuss with the patient's gastroenterologist whether this medication should be restarted. medications on admission: -asacol 1600mg tid -aspirin 325 mg qday -toprol xl 100 mg qday -calcium 500 mg tid with meals -cipro 250 mg po bid -cymbalta 60 mg qday -diovan 80 mg qday -folic acid 1 mg qam -hydroxyzine hcl 25 mg prn itching -lantus 68u at bedtime -lasix 20 mg po qod prn weight >195 lbs. -lidoderm 5%--place patch on affected region for 12 hours at a time -lomotil 2.5 mg-0.025 mg/5 ml-- ml po qid prn diarrhea -neurontin 1600 mg tid -nystatin 100,000 unit/ml--10 ml suspension(s) po qid -oxycodone 2.5 mg po q4-6h prn pain -oxycontin 40 mg po tid -plavix 75 mg po qday -simvastatin 20 mg po qday -topamax 100 mg qday -vitamin d 800 unit qday -creon 4 capsules tidac discharge medications: 1. mesalamine 400 mg tablet, delayed release (e.c.) sig: four (4) tablet, delayed release (e.c.) po tid (3 times a day). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 5. cymbalta 60 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. valsartan 80 mg tablet sig: one (1) tablet po daily (daily). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po twice a day as needed for itching. 9. insulin glargine 100 unit/ml solution sig: sixty eight (68) units subcutaneous at bedtime. 10. lidoderm 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) patch topical once a day as needed for pain: on for 12h off for 12h: apply to affected area. 11. lomotil 2.5-0.025 mg tablet sig: one (1) tablet po every six (6) hours as needed for diarrhea. 12. neurontin 800 mg tablet sig: two (2) tablet po three times a day. 13. oxycodone 20 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q8h (every 8 hours). 14. oxycodone 5 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 15. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 16. simvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 17. topiramate 100 mg tablet sig: one (1) tablet po daily (daily). 18. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 19. enoxaparin 30 mg/0.3 ml syringe sig: thirty (30) mg subcutaneous q24h (every 24 hours). 20. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po bid (2 times a day). 21. amylase-lipase-protease 33,200-10,000- 37,500 unit capsule, delayed release(e.c.) sig: four (4) cap po tid w/meals (3 times a day with meals). 22. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 23. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed for constipation. 24. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 25. ceftriaxone-dextrose (iso-osm) 1 gram/50 ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 6 weeks: should continue until appointment with dr. on . 26. vancomycin 500 mg recon soln sig: 1250 (1250) mg intravenous q 24h (every 24 hours) for 6 weeks: should continue until appointment with dr. on . 27. outpatient lab work weekly chem-7, cbc with diff, esr, crp, lfts, vancomycin trough to be faxed to infectious disease division, - fax # (. discharge disposition: extended care facility: hospital discharge diagnosis: right knee septic arthritis septic shock acute renal failure post op delirium - resolved diabetes mellitus type 2 history of hypertension chronic diastolic heart failure crohn's disease anemia of chronic disease chronic kidney disease stage 3 discharge condition: stable, afebrile discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet you were admitted for an infection. it was thought to be due to your infected knee. you were treated with iv antibiotics which you will need to continue for 6 weeks. you were evaluated by the orthopedics service, and you had to have your arthroplasty (knee hardware) removed. you had a temporary replacement in there which will need to be removed and new hardware placed in 6 weeks. in 2 weeks, you will need your staples removed. physical therapy felt that you need inpatient physical therapy at a rehabilitation facility. please take all medications as prescribed. please keep all scheduled appointments. if you develop any of the following concerning symptoms, please call your pcp or go to the ed: chest pains, fevers, shortness of breath, worsening leg pain or swelling, diarrhea, inability to take food or fluids. followup instructions: provider: , md phone: date/time: 10:30a provider: , : date/time: 2:50 provider: , md phone: date/time: 10:45 01:40p , a. , clinic (sb) 01:20p x-ray ortho scc2 sc clinical ctr, x-ray ortho scc2 provider: . phone: date/time: 2:00 procedure: venous catheterization, not elsewhere classified arthrotomy for removal of prosthesis without replacement, knee insertion or replacement of (cement) spacer diagnoses: anemia in chronic kidney disease coronary atherosclerosis of native coronary artery congestive heart failure, unspecified alcoholic cirrhosis of liver acute kidney failure, unspecified unspecified septicemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified other opiates and related narcotics causing adverse effects in therapeutic use percutaneous transluminal coronary angioplasty status chronic kidney disease, stage iii (moderate) regional enteritis of unspecified site septic shock rheumatoid arthritis hypovolemia drug-induced delirium knee joint replacement diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled chronic diastolic heart failure lumbosacral spondylosis without myelopathy pyogenic arthritis, lower leg infection and inflammatory reaction due to internal joint prosthesis 

Answer: The patient is high likely exposed to