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: history of present illness: this patient is a 58 year old man with a history of congenital bicuspid aortic valve, who is status post an aortic valve replacement with a type valve on , who presented to hospital on , with bright red blood per rectum while on coumadin and aspirin. apparently the patient had an uncomplicated aortic valve replacement procedure and was discharged in a stable condition on coumadin and aspirin and developed a massive gastrointestinal bleed of unclear etiology. he presented to an outside hospital with a hematocrit of 25.6, down from 35.0 most recently, and with an inr of 3.9. the patient was transfused approximately four units of fresh frozen plasma and packed red blood cells. the patient underwent a bleeding scan at the outside hospital which showed uptake in the proximal small bowel. nasogastric tube lavage was negative in the emergency department at the outside hospital. esophagogastroduodenoscopy was performed and showed active bleeding in a postbulbar duodenal ulcer with a large clot. this was closed with epinephrine. the patient continued to have massive gastrointestinal bleeding with a hematocrit nadir of 14.0 by report. post his esophagogastroduodenoscopy with his sclerosis, there was recurrence of melena and a repeat esophagogastroduodenoscopy showed clean based ulcers in the duodenum. his hematocrit was brought up to approximately 18.0 after aggressive packed red blood cell transfusion. upon transfer to , the patient was receiving his tenth unit of packed red blood cells with the most recent hematocrit 20.7 after nine units of packed red blood cells. in summary, the patient was transferred to as an admit to the medical intensive care unit for further stabilization of his ongoing gastrointestinal bleeding. the patient at this time was denying any nausea, vomiting, no abdominal pain, no fevers, chills, no chest pain, no shortness of breath. past medical history: 1. congenital bicuspid aortic valve. 2. hypertension. 3. right toe amputation of second digit. 4. status post aortic valve replacement with a type valve on . 5. venous stasis of lower extremities. 6. cardiac catheterization on , showing clean and patent coronary arteries. allergies: no known drug allergies. medications on home before day of admission: 1. coumadin 10 mg once daily. 2. aspirin 81 mg once daily. 3. lopressor 75 mg p.o. twice a day. 4. norvasc 10 mg twice a day. social history: the patient denies any alcohol use. there is a distant history of tobacco use. he apparently quit smoking cigarettes approximately thirty-one years ago. the patient is married and has two grown children. family history: the patient denies any family history of colon cancer but does have a family history of hypertension and prostate cancer in his father. physical examination: on the day of admission, temperature was 99.2, pulse 116, blood pressure 128/62, respiratory rate 16, oxygen saturation 99% in room air. in general, he is a middle age man, obese, well developed, in no acute distress. head, eyes, ears, nose and throat examination showed anicteric skin, mucous membranes dry. neck veins were flat. the oropharynx was clear. the chest was clear to auscultation bilaterally. his heart was regular, tachycardic, mechanical click noted, no murmur. the abdomen was soft, mildly distended, but nontender with active bowel sounds. extremities had trace bilateral edema in the lower extremities. rectal examination showed bright red blood per rectum with good rectal tone. neurologic examination was nonfocal. the patient was alert and oriented times three, 5/5 strength in both upper and lower extremities in flexors and extensors with cranial nerves ii through xii evaluated and no deficits found. laboratory data: on the date of admission, chem7 panel included sodium 142, potassium 3.5, chloride 107, bicarbonate 19, blood urea nitrogen 32, creatinine 0.9, glucose 164. electrocardiogram showed sinus tachycardia at 102, poor r wave progression. there were no old electrocardiograms to compare. the patient reportedly had flat cardiac enzymes at the outside hospital. hospital course: therefore, the patient was admitted to the medical intensive care unit at with gastrointestinal consultation for further workup of his persistent bright red blood per rectum requiring multiple ten plus transfusions of red blood cells and fresh frozen plasma despite his sclerosing of bleeding duodenal ulcers at the outside hospital, the patient also had adequate intravenous access on the day of presentation to emergency department including three peripheral intravenous sites, large bore. gastroenterology consultation proceeded with repeat esophagogastroduodenoscopy due to the patient's increased tachycardia and recent maroon stools. the esophagogastroduodenoscopy report showed three clean based ulcers found in the second part of the duodenum. after multiple sweeps of the duodenum, there was no other evidence of active bleeding or of any visible vessels. due to the negative esophagogastroduodenoscopy report and the fact that the patient had a reported repeat episode of a 1200cc red blood from the rectum, the patient went to interventional radiology for an angiogram to determine if he was a candidate for embolization. the patient was taken to the angiogram suite and a pseudoaneurysm of a branch of the gastroduodenal artery was seen and successfully embolized with no major complications during the procedure. the patient's vital signs remained stable during this time. after the patient's embolization, he was returned to the medical intensive care unit for close monitoring and serial hematocrit checks. he had no further episodes of gastrointestinal bleeding, however, the patient went into rapid atrial fibrillation of apparently new onset with a ventricular response rate of approximately 120 beats per minute. although he was asymptomatic, heparin drip was started and a cardiology consultation was obtained to help manage the patient's anticoagulation and for possible direct current cardioversion of his atrial fibrillation in the premise of his recent gastrointestinal bleeding. the patient was then scheduled for direct current cardioversion the following day. beta blocker was continued and the patient's heparin drip slightly scale was targeting a partial thromboplastin time of approximately 40 to 50 in consultation with gastroenterology to lessen the risk of rebleeding. it should also be noted that after several blood cultures were drawn in the medical intensive care unit, the patient did grow out one blood culture set of coagulase negative staphylococcus. now that the patient was stabilized with his serial hematocrits all returning approximately 31.0 to 33.0 over a period of two days, it was decided to transfer him to the floor. his heparin drip was continued at this time. his hematocrit as mentioned was approximately 32.0. he remained afebrile and his blood pressure and heart rate also remained stable. his oxygen saturation remained approximately 95% on two liters nasal cannula. because of the patient's blood culture one set growing coagulase negative staphylococcus aureus, the patient was started empirically on vancomycin one gram q12hours and infectious disease consultation was obtained in the setting of the patient's prosthetic aortic valve and the suspicion of possible endocarditis. after looking at the data, the infectious disease team determined that his chances of having true prosthetic valve endocarditis were extraordinarily low. he was not ordered for an echocardiogram to assess but antibiotics were stopped at this point and the patient was simply observed for onset of fever. the plan was to repeat the blood cultures in approximately ten days after stopping the vancomycin. the patient successfully underwent direct current cardioversion into normal sinus rhythm and has remained in normal sinus rhythm for the remainder of his hospital stay. during this time, the patient was continued on protonix 40 mg intravenously twice a day. his heparin drip was continued and his access was maintained with two 18 gauge peripheral intravenouses. red blood cell products were made available but were not required the remainder of his hospital stay. the patient's hematocrit remained stable in the 30.0s and trended upward to approximately 39.0 before the day of discharge. the patient had no recurrent gastrointestinal bleeding. the patient's vital signs remained stable for the rest of his hospital stay. it was then determined that the patient should undergo screening colonoscopy to determine if he had any other sources of bleeding. the patient's heparin was stopped and colonoscopy was performed which showed diverticulosis of the descending colon, grade i internal hemorrhoids, otherwise normal colonoscopy. there was one polyp found in the sigmoid colon which was biopsied. the patient's heparin drip was restarted and also a gastrin level was obtained to assess for the etiology of the patient's multiple duodenal ulcers. the patient was restarted on his heparin drip successfully and was started on coumadin at this time. again, the patient remained in normal sinus rhythm on telemetry and had no recurrence of his atrial fibrillation. he also remained afebrile with stable blood pressure and heart rate. the patient did develop a maculopapular rash, diffuse, symmetric across his trunk, back and lower extremities. it was quite pruritic. a dermatology consultation was obtained and the patient was managed quite well with topical steroid and antifungal creams as well as sarna lotion and atarax and benadryl for the pruritus and the rash improved quite well the last few days of his hospital stay. the patient's diet was advanced back to a full house diet and the patient was ambulatory with normal bowel and bladder function. the patient remained asymptomatic as far as abdominal pain or bleeding and was having normal guaiac negative stools the last day of his admission. the night before the patient's projected discharge date he did develop a right first toe metatarsal inflammation which appeared to be a gouty arthritis flare-up. the patient has no history of gout and no family history of gout. therefore, rheumatology consultation was obtained who believe the patient could be managed conservatively at this point on prednisone 20 mg once a day for approximately a weeks course. this was also discussed with gastroenterology and colchicine and indomethacin will be avoided in this case due to the patient's recent gastrointestinal bleeding. the rheumatology team plans to aspirate the joint on the patient's day of discharge to insure diagnosis of gout. therefore, the patient's projected discharge date is still . condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. aortic valve replacement. 2. gastrointestinal bleeding with duodenal ulcers. 3. hypertension. 4. drug rash. 5. likely new onset of gout right big toe. 6. status post embolization of a branch of his gastroduodenal artery. 7. status post direct current cardioversion for intermittent atrial fibrillation and has remained in normal sinus rhythm. medications on discharge: 1. metoprolol 75 mg p.o. twice a day. 2. protonix 40 mg p.o. twice a day. 3. coumadin 5 mg p.o. q.h.s. 4. hydroxyzine 25 mg one tablet p.o. q4-6hours as needed. 5. nystatin. 6. triamcinolone cream 0.1% one topical application twice a day applied to rash. 7. camphor menthol cream or sarna lotion 0.5% one application topically three times a day to itching rash. 8. benadryl 25 mg capsule one p.o. q6hours p.r.n. itching. 9. prednisone 20 mg tablet p.o. once daily for a duration of one week. please also note the patient's blood cultures were repeated on the day before discharge to insure clearance of any possible bacteremia. follow-up plans: 1. the primary care physician, . , was contact and the message was left. the patient will be contacting dr. office early next week to arrange inr checks and blood draws to titrate his coumadin doses. 2. also, the patient will be called by the clinic if his biopsy results are abnormal. he does not require any specific follow-up with the gastroenterology team at , only as needed. 3. the patient is recommended to follow-up with his cardiothoracic surgeon within two to four weeks to reevaluate the status of his recent aortic valve replacement. he should also follow-up with his cardiologist in conjunction with the cardiothoracic surgeon to evaluate his cardiac status. , m.d. dictated by: medquist36 procedure: other endoscopy of small intestine atrial cardioversion endoscopic polypectomy of large intestine arteriography of other intra-abdominal arteries arthrocentesis other endovascular procedures on other vessels transfusion of packed cells diagnoses: unspecified essential hypertension atrial fibrillation bacteremia cellulitis and abscess of upper arm and forearm dermatitis due to drugs and medicines taken internally chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction aneurysm of other visceral artery 

Answer: The patient is high likely exposed to