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: heparin agents attending: chief complaint: pna, aortic stenosis major surgical or invasive procedure: intubation at other hospital bronchoscopy at other hospital tracheostomy peg tube placement history of present illness: 75f h/o copd, severe as, admitted to osh with 1 week of weakness, shortness of breath, and decreased oral intake. she was ultimately found to have rll pna, gpc bacteremia, and chf, resulting in transfer to the icu and subsequent intubation. she is transferred to because of difficulty extubating. . as above, she presented on , vs= 98.0 138/70 78 18. cxr revealed rll consolidation and bilateral pleural effusions. wbc 17.4, hgb 11.8, na 121, cre 0.8. she was admited to the medical floor for treatment of pna and hyponatremia, with ctx/azithromycin, and gentle ivf hydration. . on , pt desaturated to the the 80s, with bp 180-200, she was placed on bipap and transferred to the icu and ultimately intubated. blood cultures from returned positive for gpcs x2 sets (strep salivaria), for which id consult obtained, and patient started on vancomycin 1g q12h, azithromycin stopped. per discharge summary, she was intermittently diuresed in the icu with lasix. . cardiology consult was obtained given concern for chf on cxr and known severe aortic stenosis. recs were to rule out endocarditis with tte, and obtain renal and pulmonary consults. tte on was obtained which revealed normal lv function and critical as (0.2cm). repeat tte on raised concern for mitral valve vegetation. after discussion of possible valvular intervention, pt was referred to given her previous valvular surgery here. . on pt was noted to have moderate amounts of blood from her et tube. an emergent bronchoscopy was performed, while pt was on coumadin and lovenox, which revealed bleeding from the inferior segment of the lingula on teh left, into which 10ml of epinephrine were injectied in addtion to cautery. an area of exposd vessel was also noted at the carina beween the anterior an lateral subsegement of the lll was also cauterized. cxr at that time revealed an effusion on teh right side which was drained via thoracentesis, removing 800cc of yellow fluid. . a urology consult was obtained given hydronephrosis (r kidney 10.9, left 10.2, with mild hydronephrosis), which recommended monitoring the patients creatinien and consideration of ct abd/pevlis. . pt was transferred to today given difficulty weaning from the ventilator, concern for contribution from critical as, and consideration of valve surgery. . upon arrival to the micu, pt is off all sedation, and pulling at tube. she was given propofol to facilitate sedation. past medical history: - h/o aortic stenosis - copd (not on home o2) - s/p resection of cardiac atrial myxoma - h/o aortic valvular thrombus - chronically anticoagulated - autoimmune hepatitis - hypertension - hyperlipidemia - peri-rectal abscess - anxiety - osteoporosis - "inflammation of stomach" w/neg egd. social history: has smoked 1ppd x 30y. denies etoh or ivdu. family history: nc physical exam: vitals: 96.6 67 145/69 14 100% ac 50% 500x12 peep 10 general: intubated, sedated. heent: perrl neck: supple, no lad, jvp 12-14cm laying flat. lungs: bronchial breath sounds bilaterally, no wheezes, rales, ronchi. cv: regular rate, normal s1 + s2, 3/6 sem @ rsb, no rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. no ttp ruq, negative sign. ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: on admission: 06:57pm blood wbc-22.4*# rbc-3.59* hgb-10.9* hct-33.4* mcv-93# mch-30.5 mchc-32.8 rdw-15.6* plt ct-95*# 06:57pm blood neuts-96.9* lymphs-1.5* monos-1.3* eos-0.1 baso-0.1 06:57pm blood pt-19.5* ptt-48.7* inr(pt)-1.8* 06:57pm blood glucose-241* urean-67* creat-1.5* na-143 k-3.7 cl-101 hco3-32 angap-14 06:57pm blood albumin-2.7* calcium-8.1* phos-4.8* mg-2.5 06:57pm blood alt-65* ast-67* ld(ldh)-404* ck(cpk)-39 alkphos-230* totbili-1.7* 07:21pm blood lactate-2.0 07:21pm blood type-art po2-111* pco2-61* ph-7.37 caltco2-37* base xs-8 . 6/11-13/09 bcx: no growth. bcx: ngtd. . ecg: sinus rhythm with frequent atrial premature beats and occasional atrial bigeminy. left anterior fascicular block. possible prior anteroseptal myocardial infarction. compared to the previous tracing of there is frequent atrial ectopy. the other findings are generally similar. . cxr: 1. et tube in standard position. 2. findings consistent with pulmonary edema and emphysema and persistent right pleural effusion. abd u/s: 1. gallbladder sludge with wall thickening, which may be secondary to the patient's low albumin. no cholelithiasis. no specific sign of cholecystitis. 2. urothelial thickening involving the renal pelves bilaterally, right greater than left, and given the bilateral findings, this may represent chronic urinary tract infections, particularly fungal. clinical correlation is recommended. also increased echogenicity of the kidneys bilaterally, likely reflecting chronic medical renal disease. 3. subtle diffuse hepatic nodularity, suggesting the possibility of chronic liver disease. 4. bilateral pleural effusions and minimal ascites. . tte: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. overall left ventricular systolic function is normal (lvef 70%). the right ventricular cavity is dilated with focal hypokinesis of the apical free wall. the aortic valve leaflets are severely thickened/deformed. the mitral valve leaflets are moderately thickened. there is a large globular mass on the posterior mitral valve leaflet. there is severe mitral annular calcification. there is moderate thickening of the mitral valve chordae. there is mild functional mitral stenosis due to mitral annular calcification. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the left atrial myxoma is no longer present. there is now a mass on the posterior mitral leaflet consistent with endocarditis. . ct chest: gravity-dependent consolidative opacities bilaterally with high attenuation material in the left base suggestive of hemorrhage. this is consistent with combination of atelectasis, hemorrhage, and infection. . ct head w/o contrast: . ct neck w/o contrast: . mri brain: there are multiple small areas of acute infarct seen in both supra- and infratentorial regions. in both cerebral hemispheres, multiple small areas of infarcts are seen in the frontal, parietal and occipital lobes as well as in the periventricular region and both thalami. in the posterior fossa in both cerebellar hemispheres, left middle cerebellar peduncle and right side of the pons demonstrate foci of acute infarct seen. there is a small area of blood product seen in the left parietal subcortical region as seen on the previous ct. there is no midline shift or hydrocephalus. mild brain atrophy is seen. suprasellar and craniocervical regions are normal on the sagittal images. fluid is seen in both mastoid air cells which could be related to intubation. impression: multiple bilateral acute infarcts in the supra- and infratentorial region. given the widespread distribution, likely are embolic. . mra of the head: head mra demonstrates bilateral fetal posterior cerebral artery with consequent small vertebrobasilar system. no vascular occlusion or stenosis seen. impression: no significant abnormalities on mra of the head. brief hospital course: 75f with h/o aortic stenosis, copd, admitted to osh with pneumonia, complicated by hypoxic respiratory failure requiring intubation, arf, transferred for difficulty weaning and question of valvuloplasty . # hypoxia: likely multifactorial, with contributions from apparent rll pna, pulmonary edema 2/2 systolic chf requiring intermittent diuresis, rll pleural effusion s/p 800cc thoracentesis (transudative), and an episode of pulmonary hemorhhage felt anticoagulation. she continued a course for hap with vanc/zosyn. she was intermittently diuresed for volume overload and kept net even daily thereafter. ct chest showed hemorrhage, atelectasis and evidence of severe copd. for the copd, she was continued on prednisone taper and bronchodilators. sputum cultures grew only yeast which was thought to be contaminant. bronchoscopy was performed and showed blood near lingula -> likely from suction trauma in setting of high inr. no interventions other than cold saline injections were done. hct was followed and remained stable. weaning of vent attempted without success. she eventually underwent tracheostomy on . . # mitral valve endocarditis: shown on tte here. cultures from osh grew strep salivarius sensitive to pcn, and abx switched from vanc to pcn on . id consulted and recommended continuing pcn x 6 weeks with evaluation of oral cavity for abscess. panorex not done as pt unable to stand for study. all blood cx here neg to date. . # aortic stenosis: report of critical as on tte at osh. unclear what her baseline functional status is, as per her husband, she does not have regular angina, or syncope. she had been "sleeping all the time" the past few weeks, so unclear if she has been having symptoms of chf. per osh discharge summary, she was transferred here for discussion of valve surgery/valvuloplasty. tte here showed critical as with valve area of 0.5 and peak gradient of 151. thought this may be contributing to difficulty in weaning off vent. cardiology was consulted and recommended diuresis. pt was started on low rate lasix gtt. cardiology evaluationed for valvuloplasty and felt that she was extremely high risk and recommended not to proceed with valvuloplasty. # arf: no known renal dysfunction. found to have mild left hydronephrosis at osh, and seen by urology with plan to follow clinically. ddx currently includes pre-renal diuresis vs aortic stenosis, ain antibiotics, vs obstruction. renal u/s showed potential chronic uti, especially fungal. urine cx grew yeast despite foley changes; id recommended no further treatment as the fungal infection would only return in 14 days after treatment. # anemia: hct slowly trended down over several days in the hospital. hemolysis labs negative. likely from oozing from trach site. heparin gtt discontinued. transfused two units prbcs with appropriate bump in hct. # transaminitis: h/o autoimmune hepatitis, baseline unclear. lfts normal on admission to osh, and on discharge alt 49, ast ast 51, amylase 238. abdominal u/s and ct abd/pelvis at osh without evidence of ruq process, although though elevated inr and low albumin suggest cirrhosis. ruq u/s here consistent with chronic liver disease and lfts remained stable throughout stay. # rue weakness: patient was noted to stop moving rue on in the am. unclear when this started but could move all extremities the day before. head ct showed likely emboli, and mri showed multiple foci of emboli. neurology was consulted and said may need to reassess the need for ct surgery. ct surgery was consulted who felt that she was not a surgical candidate for multiple reasons including hit positivity, recent embolic events, renal failure, operative mortality for two valves, and significant aortic valvular calcifications. # thrombocytopenia: hit positive here, serotonin release assay returned marginally positive. all heparin products were held. thrombocytopenia improved somewhat, although platelets slowly trending down again prior to discharge. # h/o aortic valvular thrombus: chronically anticoagulated, although held in the setting of significant pulmonary hemhorrage. anticoagulation was discontinued here after tte showed no atrial thrombus. # c. difficile colitis - prior to discharge, she was found to be c. difficile positive and started on po vancomycin since she was not actively having diarrhea. it is recommend she continue on po vancomcyin until her course of pencillin is completed. # sacral decub: admitted with stage 2 sacral decub. was placed on air mattress. wound care was consulted and recommended dressing changes. . # oa: receiving morphine 2mg po prn pain. per husband, she takes percocet at home for pain, but he is unsure for what. a rheumatology note indicates she takes percocet for chronic intermittent chest wall pain. continued morphine 0.5mg iv q6hr prn pain. . # anxiety: per husband, takes anti-anxiety medications at home, and receiving lorazepam 0.5-2mg q1hr prn agitation at osh. continued prn ativan, and monitored for s/sx of withdrawl. . # elevated fsbs: no known history of dm, but on steroids, with elevated fsbs. covered with hiss. . # h/o svt: cardizem in setting of severe as. . # goals of care: family was presented with the poor prognosis of mitral valve endocarditis in the setting of critical aortic stenosis. since the patient is not a surgical candidate, even if medical management of the mitral valve endocarditis is successful, her prognosis given the critical aortic stenosis is poor. we discussed with family plan to complete 6 weeks of iv antibiotics and attempt ventilator titration but possibility of a transition to a more palliative care approach. they will continue to discuss this decision as her clinical course plays out in rehab and would benefit from a palliative care consult in the future. # fen: peg was placed on and tfs were initiated. . # prophylaxis: pneumoboots. . # access: picc placed . # code: full code . # communication: son is health care proxy medications on admission: medications at home: - vitamin d 400 units daily - folic acid 1 mg po qdaily - cardizm 240mg po qdaily - lisinporil 20mg po qdaily - zantac 150mg po qdaily - lasix 20 mg po qdaily - coumadin - lorazepam 0.5mg po tid - percocet prn pain - advair 250/50 1 inh - prozac 10mg po qdaily . meds on transfer: - pneumoboots - heparin 500 u sc tid - prednisone 60mg po qdaily - xopenex inhaler q4hrs - morphine 2mg po prn pain - 300cc free water boluses - lorazepam 0.5-2mg q1hr prn agitation - cardizem 60mg po q6h (for h/o svt) - nitroglycerin paste 1inch q6h prn sbp > 140 - hiss - mvi - protonix 40mg iv qdaily - vancomycin 1gm iv qdaily - zosyn (unknown start date) - diamox - theophylline - coumadin discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 2. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation inhalation q6h (every 6 hours) as needed for wheezing. 4. ipratropium bromide 17 mcg/actuation aerosol : two (2) puff inhalation qid (4 times a day). 5. insulin regular human 100 unit/ml solution : as directed units injection asdir (as directed): q6h . 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 2-6 puffs inhalation q6h (every 6 hours) as needed for wheezing. 8. fentanyl 50 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours): continue to titrate down as tolerated. 9. amlodipine 5 mg tablet : one (1) tablet po daily (daily). 10. prednisone 10 mg tablet : one (1) tablet po once a day for 3 days: transition to 5mg po every other day for 6 days then off. 11. diazepam 5 mg tablet : one (1) tablet po every twenty-four(24) hours: transition off as tolerated. 12. vancomycin 125 mg capsule : one (1) capsule po q6h (every 6 hours): continue until penicillin course completed. 13. penicillin g pot in dextrose 3,000,000 unit/50 ml piggyback : one (1) pack intravenous every four (4) hours: please continue until . 14. sodium chloride 0.9% flush 10 ml iv prn line flush picc non heparin dependant. flush with 10 ml normal saline daily and prn per lumen discharge disposition: extended care facility: - discharge diagnosis: primary: - critical aortic stenosis - strep salivarius endocarditis on posterior mitral valve - right lower lobe pneumonia - bacteremia - acute on chronic systolic congestive heart failure - pulmonary hemorrhage - acute renal failure - thrombocytopenia - hit-antibody positive - clostridium deficile colitis secondary - copd (not on home o2) - s/p resection of cardiac atrial myxoma - h/o aortic valvular thrombus on chronic anticoagulation - autoimmune hepatitis - hypertension - hyperlipidemia - peri-rectal abscess - anxiety - osteoporosis - "inflammation of stomach" w/neg egd. discharge condition: hemodynamically stable. on ventilator. discharge instructions: you were transferred from another hospital for further management of your acute respiratory failure. you were able to come off the breathing machine for short periods of time but still sometimes need it at night. you had a tracheostomy placed so you could have the tube in your throat pulled. you had a pneumonia that was treated for 14 days with antibiotics. you had some trouble with your kidneys. it has been stable for many days but they are still not functioning completely normally. you had bacteria in your blood. this was from a bacterial collection on one of your heart valves. you were started on penicillin to treat this bacteria and should continue the penicillin for 6 weeks. you were also diagnosed with c. difficile colitis and started on oral vancomycin. . please take all medications as prescribed. please call your doctor of 911 if you develop chest pain, difficulty breathing, fever >101, worsening confusion, dizziness, bleeding, or any other concerning symptoms. followup instructions: please schedule follow-up with your pcp, . , within 1 week of your discharge from rehab. his office number is . procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more other endoscopy of small intestine fiber-optic bronchoscopy fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy transfusion of packed cells transfusion of other serum diagnoses: pneumonia, organism unspecified tobacco use disorder unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension adrenal cortical steroids causing adverse effects in therapeutic use acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified aortic valve disorders pulmonary collapse anxiety state, unspecified acute and chronic respiratory failure long-term (current) use of insulin osteoporosis, unspecified intestinal infection due to clostridium difficile old myocardial infarction long-term (current) use of anticoagulants pressure ulcer, lower back acute and subacute bacterial endocarditis personal history of venous thrombosis and embolism cerebral embolism with cerebral infarction streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus hydronephrosis acute on chronic systolic heart failure cerebral artery occlusion, unspecified with cerebral infarction heparin-induced thrombocytopenia (hit) pressure ulcer, stage ii other tracheostomy complications autoimmune hepatitis secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified 

Answer: The patient is high likely exposed to