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: no known allergies / adverse drug reactions attending: chief complaint: fever major surgical or invasive procedure: placement of picc aspiration of fluid from right shoulder history of present illness: mr. is a 66 yo man with aml m1-2 s/p induction currently c1d16 on hidac consolidation who presents with r shoulder pain and fatigue. seen at 7feldberg outpatient clinic for count check yesterday; he complained of feeling very poorly and requested to come in early, gait was unstable & he used a wheelchair. he states that since sleeping on his r shoulder on sunday night, he has had pain in the shoulder and difficulty moving it secondary to pain. states that he was unable to sleep at all the past two nights secondary to the pain. his vital signs at clinic the day prior to admission were bp 129/86, hr 116 t 98.2 rr 18 o2 sat%: 98%. his labs were wbc 0.1 hgb.7.8/hct.21.8 and platelets 5; he was transfused with 2u prbc and 1 bag of platelets. . today the patient reports that he was feeling extremely fatigued and so called an ambulance. he was taken to an outside hospital where he received vancomycin and zosyn. he was then transferred to for further management and found to have t 103.3, tachycardia to 120s, and sbp 94. blood cultures were sent and he was started on vanc/cefepime. past medical history: oncologic history: his induction chemotherapy was complicated by acute kidney injury and neutropenic fever. induction with 3+7 was unsuccessful, so he was re-induced with mec, which resulted in prolonged cytopenias and a brief icu stay for respiratory difficulty. his only sibling is not a match and a search for a matched unrelated donor has not been fruitful. he has therefore enrolled in a dendritic fusion vaccine trial (protocol 09-014) with pt1 and is now starting consolidation. . ros: he reports extreme fatigue, r shoulder pain, blood tinged mucus from right nostril. denies wght loss, headache, dizziness, visual changes, chest pain, dyspnea, cough, abd pain, back pain, constipation, diarrhea, hematochezia, hematuria, other urinary symptoms, or rash. . past medical history: - aml m1-2, normal cytogenetics, npm-1 negative, flt3 negative, s/p 3+7 induction, mec re-induction, complicated by acute kidney injury and neutropenic fever. - osteoarthritis, s/p l tka, r tha. - h/o negative colonoscopy-last . - hypertension. - seasonal allergies. - gerd. social history: never married, no children. lives alone. retired fireman. u.s.m.c. veteran during , stationed in okinawa. he is a never smoker, denies alcohol and illicit drug use. he frequently travels to the southwest (e.g. ). family history: thinks he had an uncle w/ liver cancer. father died of aaa, mother of ?chf. multiple family members w/ cva as cause of death. no known h/o hematologic malignancies. physical exam: vs: 100.8 105 102/65 76 96%3l nc. gen: nad heent: mm dry, op clear without lesions, exudate, or erythema. cv: tachy s1+s2. pulm: bibasilar crackles (r>l) abd: s/nt/nd _bs ext: trace edema bilaterally. msk: right shoulder pain to active and passive motion. neuro: aox3, cn ii-xii intact. pertinent results: admission labs: 11:10am blood wbc-0.1*# rbc-2.45* hgb-7.8* hct-21.8* mcv-89 mch-31.8 mchc-35.6* rdw-15.7* plt ct-5*# 12:45pm blood neuts-0* bands-0 lymphs-87* monos-13* eos-0 baso-0 atyps-0 metas-0 myelos-0 11:10am blood hypochr-normal anisocy-1+ poiklo-normal macrocy-normal microcy-normal polychr-normal 11:10am blood plt smr-rare plt ct-5*# 12:45pm blood pt-13.4 ptt-25.3 inr(pt)-1.1 12:45pm blood fibrino-787*# 05:55pm blood gran ct-0* 11:10am blood urean-24* creat-1.1 na-137 k-4.0 cl-102 hco3-26 angap-13 11:10am blood alt-65* ast-31 ld(ldh)-157 alkphos-186* totbili-1.1 12:00am blood probnp-4078* 12:45pm blood albumin-3.8 calcium-8.8 phos-3.9 mg-1.6 micro: blood cultures- , , , - no growth. c. diff- , - negative . 10:00 am joint fluid source: right shoulder. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. jt fluid- 2500 wbc; 0% polys . 1:25 pm joint fluid source: r shoulder. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. jt fluid- 4500 wbc; 83% polys . 4:00 pm fluid,other right shoulder. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. studies: ttecho: the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta and aortic arch are mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the left ventricular systolc function is now less vigorous (low normal) but without regional dysfunction. valvular morphology is similar. ekg: sinus tachycardia. otherwise, normal tracing. compared to the previous tracing st-t wave changes are less prominent and the q-t interval is shorter. ruq u/s: the liver demonstrates no definite focal or textural abnormality. there is no biliary dilatation. the cbd is normal in caliber, measuring 4 mm. the portal vein demonstrates normal hepatopetal flow. the gallbladder appears mildly distended without evidence of internal stone or sludge. previously seen tiny anterior wall gallbladder polyp is not demonstrated on current exam. there is no gallbladder wall thickening or pericholecystic fluid. a 3.6 cm simple upper pole right renal cyst is unchanged. there is no perihepatic fluid. partially visualized pancreas appears within normal limits. no elicited sign. impression: 1. no focal liver abnormality. 2. mildly distended gallbladder without wall thickening or pericholecystic fluid. 3. stable simple right renal cyst. ct chest/abdomen/pelvis- 1. multifocal bilateral ground-glass opacities represent either infectious or inflammatory foci. 2. small amount of new, intermediate density peritoneal and pelvic fluid, but no evidence of organized chest, abdominal or pelvic fluid collections to suggest abscess. 3. unchanged, enlarged pulmonary artery measuring 4 cm consistent with pulmonary hypertension. ct head- there is no evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. there is bifrontal cortical atrophy. sinus mucosal disease is again seen with increased opacification of the anterior ethmoid air cells, increased mucosal thickening and a mucus retention cyst in the left sphenoid sinus, and mild mucosal thickening in the maxillary sinuses. visualized bony structures are grossly unremarkable. mri r shoulder- 1. small glenohumeral joint effusion. extensive subacromial/subdeltoid bursitis. in the setting of neutropenia and fever, infection is a primary consideration. in presence of full-thickness rotator cuff tear, bursal fluid is in direct communication with joint space. the bursal fluid is amenable to ultrasound guided aspiration. 2. extensive myositis; the differential diagnosis is broad and includes infection among other causes for myositis. 3. full-thickness tear of supraspinatus tendon with retraction. 4. tendinopathy of the infraspinatus tendon. 5. long head of the biceps tendon tear. 6. abnormal signal in superior and inferior labrum. 7. moderate ac joint arthropathy. 8. abnormal signal in the posterior right lung, suboptimally evaluated on this nondedicated study. should further investigation be required, this would be better evaluated with ct. r shoulder u/s: two focal fluid collections about the right shoulder, the larger measuring 3.0 x 1.9 x 0.5 cm and located along the anterolateral aspect of the joint. : rue venous u/s: no evidence of right upper extremity dvt. chest ct: many new predominantly peripheral nodules, a couple with cavitation, as well as increasing mixed consolidative and ground-glass opacity in the lingula. although differential considerations include the possibility of septic emboli, the appearance is not entirely typical, and atypical etiologies of infection including the possibility of aspergillosis should be considered in the appropriate clinical setting. ttecho: conclusions the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef >55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). no masses or vegetations are seen on the aortic valve. there is no aortic valve stenosis. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no echocardiographic evidence of endocarditis. preserved regional and global biventricular ventricular systolic function. compared with the prior study (images reviewed) of , heart rate is slower. estimated pulmonary artery pressures are lower. left ventricular function is slightly more vigorous. . discharge labs: na 139 cl 103 bun 14 gluc 87 agap=14 k 3.9 hco3 26 cr 0.9 comments: glucose: if fasting, 70-100 normal, >125 provisional diabetes ca: 9.3 mg: 2.0 p: 5.0 alt: 17 ap: 257 tbili: 0.8 alb: 3.3 ast: 16 ldh: 178 dbili: tprot: : lip: source: line-picc wbc 2.6 hgb 8.9 24.8 plts 76 n:52 band:0 l:20 m:26 e:0 bas:0 atyps: 1 myelos: 1 hypochr: normal anisocy: 1+ poiklo: 1+ macrocy: 1+ microcy: 1+ polychr: 1+ spheroc: 1+ ovalocy: 1+ schisto: occasional comments: manually counted plt-est: very low other hematology gran-ct: 1378 source: pt: 13.7 ptt: 26.9 inr: 1.2 brief hospital course: 66 year old male with history of aml s/p 7+3 therapy and d17 s/p cycle 1 hidac on presentation, admitted with right shoulder pain and fatigue. # mssa sepsis: patient was initially admitted to bmt floor service and treated with vanco and cefepime with intermittent hypotensive which improved after 4l ivf and 1 unit prbc. morning after admission, patient developed a new o2 requirement and was felt to be volume overloaded, and so received 30 mg iv lasix. osh blood cultures were then found to be positive for s.aureus (within 12 hours) () and he received a dose of linezolid in addition to vancomycin. he then was febrile to 102 and was found to be hypotensive to sbp 70s that was unresponsive to 1l ivf. he was started on peripheral levophed and transferred to the for further management. he was started on vancomycin, cefepime, and linezolid for empiric therapy for febirle neutropenia. he required a brief period of pressor support with norepinepherine as his map was <60 on icu admission. during this time, he was also experiencing right shoulder pain. joint space aspiration revealed 2500 leukocytes concerning for a septic joint. his blood cultures from osh grew out mssa. tte was negative for valvular vegetations. his abx therapy was down graded to nafcillin and ciprofloxacin by icu day #3. however, due to recurrent low grade fevers, he was placed on fluconazole. a thoracic ct scan as well as head ct were performed to look for an indolent infection/abscess/phlegmon. ct's failed to reveal a distinct collection, though did show multifocal bilateral ground-glass opacities. he continued to have low grade fevers which were attributed to a possibly septic joint/shoulder infection. he was transferred back to the floor after a 4 day icu stay and his antibiotics were reduced to primarily nafcillin, with fluconazole and acyclovir for ppx. he remained febrile until after undergoing two further drainages of the fluid from his shoulder (see below). after the second drainage, patient was afebrile for the rest of his hospitalization and continued on nafcillin without event. he underwent repeat chest ct when an cxr showed possible progression of the earlier opacities/nodules and this showed new predominantly peripheral nodules, a couple with cavitation, as well as increasing mixed consolidative and ground-glass opacity in the lingula concerning for septic emboli. pulmonology was consulted and recommended tte (please see note for further details). patient underwent a repeat tte to assess for valvular disease which was negative. tee was deferred secondary to the patient's low platelets. to follow up- - patient will need repeat chest ct in months to assess progression of nodules and ground glass opacities - urine histoplasma and galactomannan pending on discharge . # febrile neutropenia: presented s/p 7+3 therapy and c1d17 from hidac. fevers were thought to be due to mssa septicemia in conjunction with septic joint. neutropenic chemotherapy. started on filgastrim and continued until counts recovered. . # r septic shoulder: on presentation patient had extreme right shoulder pain. orthopedics was consulted and felt that his symptoms were secondary to a rotator cuff tear though septic joint was in the differential. they tapped the shoulder- joint fluid showed 2500 leukocytes- elevated in the setting of leucopenia concerning for septic arthritis. as the patient's neutropenia resolved his shoulder swelled up signficantly and pain worsened. he underwent mri of the shoulder which showed joint effusion, extensive subacromial/subdeltoid bursitis, extensive myositis of the shoulder girdle and a full thickness rotator cuff tear. the patient underwent two subsequent taps, one by ortho (appx 2 ccs) and the final by ir (appx 10cc), which showed 2+ polys and no organisms on gram stain or culture. the patient became and remained afebrile after the third tap. he was continued on nafcillin with a planned antibiotic course of 6 weeks. . #. narrow-complex tachycardia: patient had sporadic bouts of svt while in the icu, reaching rates of about 200 bpms. usually broke svt on own, but on icu day #3 had an early morning bout of svt to 180's. given 5 mg iv metoprolol and carotid massage, bringing hr down to 100. thought to be due to fevers. bmt concerned of possible intracrdiac/valvular infection which may be affecting conduction system. no signs of infectious collection seen on imaging. started on low dose beta blocker 12.5 mg metoprolol for baseline rate control on icu day #4. the patient's heart rate was better controlled for the remainder of his hospitalization and he was discharged on this medication. . #. right calf nodule- patient with small erythematous macule on lateral right calf which progressed to a non tender erythematous nodule. derm was consulted and did not feel that this was a manifestation of septic emboli; they felt it was more likely a resolving inflammatory process. given location of nodule and patient already on optimal therapy, biopsy was not performed. . #. hypertension: patient with history of hypertension on amlodipine at home. this medication was discontinued on admission secondary to his low blood pressures in the setting of sepsis. following his icu stay, he was normotensive off of amlodipine and on metoprolol. he was discharged on metoprolol and amlodipine was discontinued. . # hyperbilirbuinemia: bilirubin slowly trending up from <1.0 to 2.7 on icu day #4. be due to recent transfusions he previously received on icu admission. ruq us did not show any cholangitic or hepatic process/obstruction. this trended down during the rest of his hospitalization. medications on admission: 1. acyclovir 400 mg tablet sig: one (1) tablet po q12h 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 3. ondansetron 4 mg tablet, rapid dissolve sig: tablet, rapid dissolves po three times a day as needed for nausea. discharge medications: 1. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 2. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 3. nafcillin in d2.4w 2 gram/100 ml piggyback sig: two (2) grams intravenous q4h (every 4 hours). 4. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 5. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 6. lorazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. discharge disposition: extended care facility: - discharge diagnosis: acute myelogenous leukemia methicillin sensitive staphylococcus aureus bacteremia right shoulder infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with fatigue and right shoulder pain. you were found to have bacteria growing in your blood and required a stay in the intensive care unit. your infection was treated with antibiotics and your condition improved. the source of your infection was believed to be your shoulder- an mri showed inflammation and tear of the muscles as well as fluid in the joints. some of this fluid was drained and your fevers resolved. please continue to take the antibiotics for six weeks. we made the following changes to your medications: - start taking nafcillin for your infection - start taking metoprolol for your heart rate and blood pressure - start taking fluconazole to prevent fungal infection - change your dose of acyclovir to 400 mg every eight hours - stop taking amlodipine for your blood pressure followup instructions: please follow up at the appointments below: department: infectious disease when: monday at 9:50 am with: , md building: lm campus: west best parking: garage department: hematology/oncology when: monday at 2:00 pm with: , md building: campus: east best parking: garage department: hematology/oncology when: monday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage md procedure: arthrocentesis arthrocentesis arthrocentesis injection or infusion of oxazolidinone class of antibiotics diagnoses: unspecified essential hypertension severe sepsis methicillin susceptible staphylococcus aureus septicemia other specified cardiac dysrhythmias septic shock antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use drug induced neutropenia jaundice, unspecified, not of newborn acute myeloid leukemia, without mention of having achieved remission pyogenic arthritis, shoulder region other fluid overload disorders of bursae and tendons in shoulder region, unspecified septic pulmonary embolism other specified aplastic anemias effusion of joint, shoulder region other atopic dermatitis and related conditions 

Answer: The patient is high likely exposed to