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 attending: chief complaint: left neck pain major surgical or invasive procedure: colonoscopy picc placement history of present illness: mr. is a 56-year-old man with a history of obesity, hypertension, diabetes, dyslipidemia, sickle cell trait, prostate cancer, multiple myeloma (s/p chemotherapy), unilateral orchidectomy, pulmonary embolism (on coumadin), sleep apnea, adjustment disorder, presenting with acute onset left neck pain, including hemibody symptoms. mr. up at 10 a.m. on with pain at the base of his neck on the left (he points to the area of the manubrioclavicular joint on the left). it was associated with neck stiffness and was aching in character. the pain worsened and came to include the posterolateral neck, slight distal from the origin of the left trapezius. his son got some for him which helped somewhat and he slept some more. he then awoke with burning pain in both feet and in his left hand. the ache had spread to his left arm and leg. he developed a headache that radiated from the pain in his neck. these symptoms brought him to the ed. review of systoms reveals a number of positive features: the pain varied slightly with breathing, he thinks. he feels that his arm was weak, but only secondary to pain, he agreed. his family noted that he was not talking much and that his speech was slurred, but he was not sure whether this was because of a speech difficulty, or because of pain. his ankles have been swollen lately so he had started lasix. he was also precribed nortrytiline to take at night - both of which started on friday. he has taken both. the swelling in his anlkes has gone now. he did notice that he was more short of breath than usual on , waited for ems to arrive before tackling the stairs to the ground floor in his house. he travels to frequently and has been there within the last few months: once in , when he actually developed diabetic coma, returning to the us in , then again in , returning on . he is not sure whether he has been dehydrated, but it has been very warm this weekend. multiple myeloma, according to the patient, was diagnosed after he visited an hematologist to work up his anemia. final diagnosis was made by bone marrow biopsy and he does not know of any bony lesions/plasmacytomas. chemotherapy was started the following week. in the ed, pain was controlled, neurology saw him and ct angiograms of the chest, neck and head were performed, along with a plain film of the neck. his pain improved with dilaudid, but did not resolve completely. his initial vitals were: t 98 hr 89 bp 161/103 rr 18 sats 99% on ra. cta of torso ruled out dissection, cta head/neck was negative for vascular injury. morphine 16mg iv, dilaudid 1mg x 1 and aspirin 325mg. other review of systems was negative: he had no recent cough, runny nose, fever, chest pressure, palpitations. no pain on chewing, visual changes. no sick contacts, no extramarital sexual relations, no smoking, drugs or alcohol. no particularly notable stressors. he check glucose frequently and injects insulin into his shoulders and thighs (not belly). he does not monitor his blood pressure at home. no gi symptoms, diarrhea, vomiting, nausea. past medical history: - sickle cell trait - no manifestations, per patient - obesity, recent bmi 31.8 - hypertension, on lisinopril, amlodipine, atenolol - diabetes, on insulin, poorly controlled per notes - cancer of the prostate, radical prostatectomy , now nocturia and frequency - leydig cell testicular tumor, s/p unilateral orchidectomy - sleep apnea - colon polyp, small adenoma on colonscopy , repeat advised - impotence, erectile dysfunction - anemia, leading to diagnosis of multiple myeloma - multiple myeloma, diagnosed by bone marrow biopsy (50% plasma cells), s/p velcade/decadron, controlled per patient, iga type, iga level 1900 in . oncologist is dr. (). no bony lesions on skeletal survery in . significant steroid toxicity per oncology note, so subsequent treatment could be revlimid or velcade alone. - dyslipidemia - alcohol abuse, dependence and some struggle to stop when starting coumadin for pe in . has been prescribed naltrexone. not active. - steatohepatitis - pulmonary embolism, on coumadin (for four months now) - difficult to keep inr stable, presently supratherapeutic. likely provoked during hospitalization for diabetic coma. admitted to from to and started coumadin. bridged with fragmin 18,000 units. - diabetic coma, glucose in 600s, occurred while in in - hospitalized there and given large amount of iv fluid, noted to also have cough and fever. also presented to urgent care with symptomatic hyperglycemia. - diabetic retinopathy - latent tuberculosis, negative afb - hypothyroidism in notes - previously on levothyroxine - lower extremity edema, given lasix, amlodipine discussed as cause also. social history: lives in with his wife. originally from . currently works for the school of public health on a project studying hiv/aids in . travels monthly to or . reports a history of etoh (~4 beers/day w/scotch, however has recently cut back to 1/day), no smoking, no illicits. family history: mother died at 98 of old age. father died at 85 of old age. physical exam: t 97.8 f hr 88 bp 167/70 ( - 179/113) respiratory: 20 rr 99 % o2sat fingerstick: 114 biometrics at admission: height: 72 in. weight: 90.72 kgs. (200.00 lbs) bmi: 27.1 present weight: 90.72 kg (but appears heavier, so will check, last bmi 31.8) fluid balance (net in 24 hr): nr physical exam gen: overweight man, unconfortable, little spontaneous movement of left arm. ice packs on upper left trapezius and region of sternoclavicular joint. neck: guarding pain, not palpable masses posteriorly. sternoclavicular joint region very tender and slightly erythematous under area that ice pack placed. cardiovascular: regular. systolic murmur that radiates to the subclavian arteries, but not the carotids, loudest at both rusb and llsb, no r/g. normal s2. normal s1, s2 at lusb. respiratory: cta throughout, good air entry, no wheeze. gastrointestinal: benign. nt, nd, bs+. extremities: unremarkable. no edema. neurological: alert, oriented to person, place, time, context. no dysathria/aphasia. cognition normal, superficially. cn ii - xii normal. guarded movements of neck, left arm, clumsy left hand but possible pain limitation (also per patient). decreased sensation at dorsum of left foot. fundoscopy, reflexes, gait and vibration sense deferred (but should be checked). psychiatric: euthymic to concerned, normal thought form, appropriate and cooperative. skin: darkened, hypotrophic, shiny skin on anterior left lower leg. pertinent results: 10:58am %hba1c-6.2* eag-131* 09:40am glucose-153* urea n-8 creat-0.9 sodium-138 potassium-3.9 chloride-96 total co2-27 anion gap-19 09:40am ck(cpk)-247 09:40am ck-mb-1 ctropnt-<0.01 09:40am tot prot-8.3 calcium-10.4* phosphate-4.3 magnesium-1.2* 09:40am pep-abnormal b igg-470* iga-633* igm-12* ife-monoclonal 09:40am wbc-9.0 rbc-4.03* hgb-12.0* hct-37.2* mcv-92 mch-29.9 mchc-32.4 rdw-15.1 09:40am sed rate-52* 04:10am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-40 bilirubin-neg urobilngn-0.2 ph-7.0 leuk-neg 04:10am urine rbc-1 wbc-1 bacteria-none yeast-none epi-1 11:40pm alt(sgpt)-90* ast(sgot)-94* ld(ldh)-497* ck(cpk)-314 alk phos-48 tot bili-0.5 11:40pm ctropnt-<0.01 11:40pm ck-mb-2 11:40pm tot prot-8.8* albumin-5.1 globulin-3.7 calcium-10.2 phosphate-5.8* magnesium-1.3* 11:40pm crp-20.8* imaging: tee: the left atrium and right atrium are normal in cavity 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. no atrial septal defect is seen by 2d or color doppler. normal left ventricular cavity size and global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation may be present. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valvular pathology or pathologic flow identified mri clavicle: impression: bone marrow edema and enhancement of the left medial clavicle and manubrium concerning for left claviculomanubrial joint infection and osteomyelitis with surrounding reactive edema. no drainable fluid collections. the left medial clavicle and manubrium are better imaged on this dedicated study and given differences in imaging technique, abnormalities likely have not significantly changed or have possibly minimally progressed since the mr . brief hospital course: mr. presents with numerous medical problems, including multiple myeloma, latent tuberculosis, h/o testicular and prostate cancer p/w acute onset left neck pain with left arm weakness in setting of cracking/stretching his neck, developing with strep bovis bacteremia of unclear source. strep bovis bacteremia: found on culture after patient was spiking fevers while in-house. subsequently grew strep bovis. empirically started vancomycin. bacteremia cleared . multiple imaging performed of patient's left neck/shoulder as he complained of significant pain in the area. mri of claviculomanubrial region was consistent with osteomyelitis and possible septic joint, however no fluid was available for aspiration. unfortunately the yield of bone biopsy in setting of antibiotics is quite low and since the pre-test probability is high for osteomyelitis in this patient, it was decided to treat presumptively for osteomyelitis. id was consulted and felt ceftriaxone would be the most effective antibiotic for strep bovis. unfortunately, the patient reported a significant pencillin allergy of facial swelling and difficulty breathing. he was transferred to the micu for ceftriaxone desensitization. this was performed without incident. colonoscopy was performed given link between strep bovis and colon cancer. patient had five polyps found, and all biopsied. pathology was consistent with adenomas. polypecetomy was deferred as patient was on a heparin gtt. in discussion with patient's pcp, was felt the patient no longer needed anti-coagulation for a provoked pe occuring in . since heparin could be safely stopped, the patient had another colonoscopy which was terminated due to a poor prep. the following day, another colonoscopy was attempted and bleeding occured after the first polypectomy, so the colonoscopy was terminated early. his hematocrit was trended and was stable, requiring no blood transfusions. he was taken back for a 4th and last colonoscopy the following day and all remaining polyps were removed. the patient had no further complications. he will need a repeat colonoscopy in one year. polyp pathology was pending at time of discharge. this was felt to be the likely source of patient's bacteremia, as no other potential source was found. notably, endocarditis ruled out. tee was performed and was negative for vegetations. patient will continue ceftriaxone for a total of six weeks with close id follow up. upper chest/neck pain: in setting of patient cracking his neck then developing acute onset left neck/back pain. imaging on presentation was consistent with significant muscle strain. it was felt the sudden movement may have also caused minor trauma to clavicularmanubrial region allowing strep bovis to seed the joint and ultimately infect the clavicle, which exacerbated the patient's pain in this area. he was initially pain controlled with iv diluadid, ultram, diazepam, gabapentin, nortryptilline, tylenol, and lidocaine patches. prior to discharge he was needing minimal po dilaudid. he was discharged on gabapentin, nortryptilline, tylenol, lidocaine patches and po diluadid. he experienced no pain prior to discharge. hypertension: hypertensive peaks appeared to occur with pain and resloved with pain control. he was continued on home amlodipine, atenolol, and lisinopril. during ceftriazone desensitization, bb and ace-i were held, but re-started prior to discharge. recent pe: reportedly developed after a long flight. was on coumadin prior to admission. cta during this admission was without evidence of pe. given patient's colonoscopy, coumadin was held and heparin gtt was started during hospitalization. patient's hematocrit was notably decreasing from 37 to 27 during hospitalization. this was felt to be due to patient's infectious state, repeated blood draws, and slight ooze from patient's polyps as he was notably guaiac positive with brown stools. heparin gtt was held and patient's hct stabilized in the upper 20s. spoke with patient's primary care physician who stated patient did not need systemic anti-coagulation given this was a provoked pe and patient has been anticoagulated for nearly six months. warfarin was discontinued during this admission. diabetes: reasonable blood sugar control. continued home lantus and hiss for coverage multiple myeloma: actively being treated in the outpatient with velcade and decadron. spep drawn consistent with iga subtype. stable disease throughout hospitalization. latent tuberculosis: uncertain significance at present. no active alcohol abuse: per wife's report, patient drinks excessively on a daily basis and she is quite concerned for his safety and health. social work consulted. patient will schedule appointment with behavioral health for further assistance. access: right picc code: full code medications on admission: not all of these medications are current. bactrim and antivirals likely given in context of velcade/decadron and naltrexone given past alcohol use. monthly zometa was also given as part of chemotherapy. fluticasone, potassium chloride slow, metformin 500 and magnesium oxide were also on his dc summary list from . - lasix 40 mg po qd - nortriptyline 10 mg, started last week, po qhs to be uptitrated to 30 mg qhs over three weeks. - insulin, sc, lantus 8 units qpm, humalog 4 units before breakfast and supper - bactrim 160-800 mg po bid on m, w, f - omeprazole 20 mg (er) po qam - naltrexone, 50 mg po qd:prn - oxybutinin cl (sr) 10 mg po qam - warfarin 5 mg po qpm - famcyclovir 250 mg po bid - amlodipine 10 mg po qd - lisinopril 40 mg po qd - atenolol 25 mg or 50 mg (unclear from notes) po qd - acyclovir 400 mg po bid discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. lantus 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. 4. insulin lispro 100 unit/ml solution sig: four (4) units subcutaneous (before breakfast and supper). 5. gabapentin 400 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): you should take this concurrently when taking pain medication. 7. nortriptyline 10 mg capsule sig: three (3) capsule po hs (at bedtime): take with food to reduce gi upset. disp:*90 capsule(s)* refills:*2* 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 10. lisinopril 40 mg tablet sig: one (1) tablet po once a day. tablet(s) 11. ceftriaxone 2 gram recon soln sig: two (2) grams intravenous every twenty-four(24) hours for 5 weeks. disp:*58 grams* refills:*0* 12. outpatient lab work every monday while on antibiotics (, , , ): cbc/diff, bun/cr, alt, ast, alkaline phosphatase, total bilirubin all laboratory results should be faxed to infectious disease r.ns. at ( 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. atenolol 50 mg tablet sig: 1.5 tablets po once a day. disp:*45 tablet(s)* refills:*2* 15. hydromorphone 2 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: do not drive or do anything that requires significant attention while taking this medication. hold for sedation. disp:*30 tablet(s)* refills:*0* 16. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for pain: apply 12 hours on and 12 hours off. disp:*10 adhesive patch, medicated(s)* refills:*0* discharge disposition: home with service facility: critical care systems discharge diagnosis: primary: strep bovis bacteremia sc joint septic arthritis presumptive sternal and manubrial osteomyelitis neck strain colonic adenomas secondary: multiple myeloma diabetes hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted because of neck pain and subsequently developed fevers. you were found to have a bacterial infection in your blood called streptococcus bovis. this caused you to have an infection in your breast bone (the sternum) as well as the joint that connects your sternum to the left clavicle, which exacerbated your neck/shoulder pain. we gave you antibiotics. the antibiotic you were initially using was not the best drug for this bacteria. since the best drug is in the same family as pencillin, of which you are allergic, you went to the icu to desensitize you to this drug. you tolerated this well. you will need a full six week course of antibiotics. ***be sure you do not miss a dose of ceftriaxone, your antibiotic. if you do miss a day, when you take another dose, you may have an allergic reaction. you should contact the infectious disease doctors if have any concerns about this. the number is below.**** we also were looking for a source of infection. you had a colonoscopy because this bacteria can commonly be in your large intestine. five polyps were found and biopsies were taken. these biopsies did not show cancer. with time, these polyps can develop into cancer and so need to be removed. you had another colonoscopy and your polyps were removed. you should follow up with your primary doctor for the full results of this. ****you must look at your stools every time you have a bowel movement for the next 3 weeks. if they appear black or red, you should come to the emergency room. this may mean you are bleeding from the polyps that were removed in your colonoscopy***** you will need a repeat colonoscopy in one year. we monitored your blood levels closely as these were drifting down. you may have been bleeding slightly from your polyps when you were on the blood thinner. we stopped your blood thinner because you do not need this anymore and your blood levels remained stable. you will follow up closely with your primary care doctor for further management. you should continue all of your medications as prescribed with the following important changes: 1. stop warfarin 2. stop lasix (you have not needed this medication) 3. increase nortriptyline to 30 mg every night. (you were taking 10 mg every night) 4. continue: ceftriaxone 2 grams iv every 24 hours for a total of 6 weeks. last dose: thursday, 5. start: gabapentin 400 mg three times per day (this is a pain medication) 6. start dilaudid 2-4 mg to be taken every four hours as needed for pain 7. stop oxybutinin as you do not need this medication anymore either it is important that you keep all of your doctor's appointments. followup instructions: you have the following appointments scheduled: 1. department: infectious disease when: thursday at 3:10 pm with: , m.d. building: lm campus: west best parking: garage 2. department: infectious disease when: tuesday at 3:00 pm with: , md building: lm bldg () campus: west best parking: garage *****all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. at ( or to on md in when clinic is closed 3. pcp: , . . date/time: :30 am procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart endoscopic polypectomy of large intestine endoscopic polypectomy of large intestine endoscopic polypectomy of large intestine endoscopic polypectomy of large intestine closed [endoscopic] biopsy of large intestine closed [endoscopic] biopsy of large intestine closed [endoscopic] biopsy of large intestine closed [endoscopic] biopsy of large intestine immunization for allergy diagnoses: anemia, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled personal history of malignant neoplasm of prostate unspecified osteomyelitis, other specified sites need for desensitization to allergens other and unspecified hyperlipidemia hemorrhage complicating a procedure bacteremia long-term (current) use of anticoagulants personal history of venous thrombosis and embolism unspecified accident streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus benign neoplasm of colon multiple myeloma, in remission sprain of neck pyogenic arthritis, shoulder region sickle-cell trait 

Answer: The patient is high likely exposed to