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 / amiodarone attending: chief complaint: aicd firing major surgical or invasive procedure: none history of present illness: this is a 68 yo male with a pmh of cad s/p cabg (lima->lad, svg->d->om2 jump graft, svg->lpda) with stents to distal and proximal lcx, s/p vt ablation and aicd implantation , who presents after his aicd fired 3 times this am. the pt was walking out from his bathroom and tripped and fell (with his headhitting the mattress), at which time his aicd fired 3 times over a 6 minute period. he denies associated syncope or associated cp, sob, n/v, diaphoresis. he has been feeling more weak over the last two weeks and has been unable to use his cane like normal because of right wrist pain. he initially presented to hospital and was transferred to for further evaluation. . per ep fellow's note, the pt was recently admitted for stable vt two days after fem-fem bypass r->l. during that hospitalization (?), the pt was initially loaded on amiodarone, but this was subsequently discontinued for concern of toxicity. the threshold on the pts icd was changed at that time. however, pt had 4 episodes of icd discharge for continued stable vt. therefore, patient was started on sotalol during previous admission. . in the ed the pt was found to have a sbp initially in the 80s and a hct of 25 (bl 31). he was given 2 units of prbc and his sbp rose to 110s. ep interrogated his paecmaker and found the pt to have had three shocks for what appears to be atach around the same rate as his vt (vt lower detection limit is 600ms). he was given toprol xl 25 mg po x1 per ep recs as well as 20 mg ivx1 and 1 l ns. . overnight patient received an additional 40 mg of iv with 300 cc of uop overnight. he was also started on 20 mg of prednisone for presumed gouty attack. this am he continues to complain of right wrist pain. he states that this is similar to prior gouty attacks. it has been going on for ~ 1 week. he has also had fevers as high as 102 in the last week reported by his visiting nurse. dose was also increased approximately 1 month ago from to tid given increased lower extremity edema and fluid on the lungs. he does not complain of anything else but when questioned, he does note that he has been more weak in the last 2 weeks. he lives alone and can normally walk with a cane or walker but has had more difficulty walking around recently. he notes that he has not been able to use his cane as he normally would because of his painful wrist. pt denies nausea, vomiting, abdominal pain, increased leg swelling, orthopnea, subjective fevers, chills. he also denies brbpr, melena, focal weakness/numbness. past medical history: 1)cad s/p cabg cabg (lima->lad, svg->d->om2 jump graft, svg->lpda) - cath(: patent lima->lad, patent svg->diagonal and om2. occluded svg-> l pda. - underwent 2->proximal and distal left circumflex/pva 2)htn 3)hyperlipidemia 4)s/p vt ablation and icd implantation 5)copd 6)gout #chronic lle ulcers #pvd/claudication - s/p right external iliac artery stent - complicated by lue hematoma, ? nerve injury; - s/p right to left fem-fem bypass grafting in #spinal stenosis - s/p back surgery #bilateral renal masses #s/p l inguinal hernia repair #s/p cataract surgery social history: single, lives alone. has visiting nurse service. active smoker of 10 cigarettes per day. has smoked 1-2 packs per day for years. denies etoh. retired construction worker. family history: non-contributory physical exam: t 98.1 bp 98/54 p 64 r 20 sat 98% 2.5l nc gen: chronically ill appearing man,resting comfortably. nad heent: ncat. no icterus. eomi, perrl, op clear, uvula midline, mmm neck: jvp at the level of the mandible. no hjr. no thyromegaly. no carotid bruits cv: distant heart sounds, rrr, nl s1/s2, no m/r/g noted lungs: bibasilar crackles. no wheezes or rhonchi ab: nabs. soft, ntnd, no hsm. no rebound or guarding extrem: r wrist erythematous, warm, swollen, and tender. no palpable effusion. 1+ pitting edema in lle up to knee, trace pitting edema in rle up to the knee. non-palpable dp/pt pulses. well-healed incision scar l calf neuro: a and o x 3. cn ii-xii grossly intact. some decreased attention on cranial nerve exam but able to follow commands. paratonia in lower extremities and rigidity to assisted range of motion but patient able to move all extremities in all ranges of motion except for right wrist. downgoing plantar reflexes bilat. le reflexes could not be performed rigidity. skin: l foot wrapped with clean dressing. not removed. per prior exam: well healing 1cm ulcer on l heel, well healing 1 cm r medial malleolus ulcer, 2 1 cm ulcerations on the dorsum of the l foot which appear non-infected and have no drainage pertinent results: pa and lateral chest radiographs: the left-sided pacemaker is seen with leads terminating in appropriate position. the patient is status post cabg and median sternotomy wires are noted. there is moderate cardiomegaly which is unchanged. the lungs are clear. the osseous structures are unremarkable. impression: no acute cardiopulmonary abnormality. . ekg: a paced, lad, ivcd, twi v3-v6 i avl avf (all old) brief hospital course: patient is a 68 yo male with a pmh of cad s/p cabg and pcis, vt ablation and aicd implantation , pvd s/p fem-fem bypass with ptfe graft who presents after aicd firing for atrial tachycardia found to be anemic, thrombocytopenic, hyponatremic, and now bacteremic with staph aureus. . 1) bacteremia: the patient had persistent high-grade mrsa bacteremia. he grew bacteria in 4 out of 4 bottles in <24 hours on admission. cultures were positive in bottles for several days. he initially spiked fevers to 102 but was asymptomatic and quickly defervesced while on iv vanc 1gm q24h. id was consulted and followed the patient throughout his hospital course. the patient was noted to have an open lle foot ulcer draining tophaceous material. swab of this wound grew mrsa representing a possible source for his bacteremia. surgery was consulted and it was decided to not surgically intervene at the site. given his persistent high grade bacteremia a source of sequestered infection was sought. tte and tee did not show vegetations. the patient's icd and graft site were visualized by u/s without any fluid collections found. it is still concerning that the patient relatively recently had his icd placed. cardiology was contact regarding this issue. the patient developed a r wrist, r knee and l 3rd finger swelling and erythema consistent with either gouty flare or septic joints. the patient's knee was tapped multiple times and was consistent with gout with an associated low grade infection growing staph aureus. the patient's r wrist had a surgical washout by hand plastics and contained gross crystals and on gram stain contained gram positive cocci in pairs and clusters. the patient had a transient decline in his blood pressure which improved after holding diuresis. at that time, the patient's lactate was 2.8. the patient's left foot was debrided by podiatry. he finally cleared blood cultures on . the patient completed a 5-day course of gentamicin (for synergy) and was continued on vanc iv alone, dosed renally. patient continued to have an elevated wbc with elevated temperatures despite treatment with vancomycin. other sources of infection were investigated, included her icd. his icd was removed and cultures of the atrial leads grew coag + staph aureus. this was thought to be his source of infection and may have triggered his episodes of vt. he was continued on vancomycin, per id reccs, and will continue this for 6 weeks from the last blood culture. last blood culture is on . . 2) ventricular tachycardia: pacemaker was interrogated and he was found to be in a tach. this may have been secondary to increased sympathetic tone s/p fall. he has had no further episodes since that time. the patient was continued on sotalol 120 mg po bid, mexiletine 150 mg po q8hrs, toprol xl 25 mg daily per ep recs. he was maintained on tele monitoring without recurrence. the patient was transferred to the ccu on after multiple episodes of sustained ventricular tachycardia. his blood pressure dropped to sbp in the low 80s. his icd did not fire at this time and the patient was asymptomatic. his device was interrogated by ep at this time and he was given a bolus of amiodarone, followed by a continuous iv infusion. while in the ccu he had occasional runs of nsvt for 5-8 beats each. his sbps remained in the 90s/100s. the sotalol was d/c'ed due to worsening renal function and he was continued on the mexiletine. the icd was removed by ep because it was thought to be his source of infection, in the context of an elevated wbc and fevers. he was then transitioned to po amiodarone but was then stopped due to elevated lfts, per hepatology recommendations. plan, per ep, is to have patient undergo vt ablation in weeks. he has not had any further episodes of vt during his stay. . 3) coffee ground emesis. the patient had a questionable episode of bloody emesis. on ng lavage coffee ground emesis were noted and the patient was sent to the micu though he was hemodynamically stable with a stable hematocrit. egd revealed diffuse esophagitis and gastritis consistent with candidal infection. the patient was started on po fluconazole. there was no clear bleeding source. the patient was transfused for a slow hct drift downward with good response and maintained a stable hct throughout the remainder of his admission. the patient was h. pylori serology negative. during the rest of his hospital stay his hematocrit remained stable and did not require any further transfusions. initially both his aspirin and plavix were stopped; but his asa was then restarted. . 4) productive cough. the patient developed a productive cough growing klebsiella and enterobacter on culture consistent with a cxr concerning for a new infiltrate. the patient was started on levofloxacin on and completed a 2 week course. it was thought that he had a new infiltrate on cxray and was started on ceftriaxone but this was d/c'ed since pt was clinically stable. . 5)chf: per the patient's tte in , he has an ef of 25% with elevated lv filling pressures (systolic and diastolic dysfunction). on presentation, pt has wet crackles, bnp of 4000, and le edema. other evidence for volume overload is hyponatremia. also be contributing to worsening renal function given known systolic dysfunction. the patient did not respond to medium dose iv and then was given 100mg iv with a goal diuresis of 500-1l. the patient was not significantly negative per i/o recording, however, crackles appeared improved. his diuresis was held during transient hypotension. he was placed on a low salt diet, fluid restricted 1.5 l/day. his regimen of sotalol, toprol xl was continued but later held because of elevated creatinine and bradycardia. lisinopril was held for renal failure. . 6)cad: the patient had no ekg changes on presentation. troponins and cks remained flat. initial elevation in troponins were likely due to combination of cardiac stretch, aicd firing, and renal failure. excellent cholesterol control. the patient was initially continued on asa, plavix, pravachol, sotalol, toprol xl. his sotalol and lisinopril were held in the setting of arf. asa and plavix were held due to possibility of gi bleed. asa was then restarted towards the end of his hospital stay. . 7)anemia. the patient presented with anemia. he had an appropriate response to transfusion with hct back to baseline and stable. b12 and folate studies were normal. iron studies were suggestive of anemia of chronic disease. possible contribution of marrow suppression secondary to sepsis. the patient had daily hct without further decline. transfusion threshold was set at hct<21. . 8) thrombocytopenia. the patient presented with thrombocytopenia. initial concern was for dic given sepsis and declining platelet count and hus given renal failure on presentation. coags were normal and dic labs were not consistent with dic. there was no evidence of hemolysis or schistocytes on smear to suggest hus. marrow suppression secondary to sepsis as the patient also presented with anemia and a low wbc count in light of significant bacteremia was thought possible. the patient was found to be heparin antibody positive. his platelet count stabilized. after withholding all heparin containing products including flushes, the patient's platelets began to climb. patient was tested for heparin dependent antibodies which were found to be positive. . 9) transaminitis: the patient presented with a mild transaminitis and elevation in alkaline phosphatase. these were nonspecific and there were no findings on history or physical consistent with biliary colic or cholecystitis. it was thought that this could be a congestive hepatopathy secondary to heart failure given evidence of r sided heart failure on exam. a ruq ultrasound was done to rule out cholecystitis and cholangitis as the patient was not covered with gram negative antibiotics. ruq ultrasound showed some gallbladder wall thickening and no acute process. patient's alt, ast and alk phos began to rise again later during his hospital stay. hepatology was consulted. ruq u/s repeated and suggested gallbladder sludge. hepatitis serologies negative. thought to be medication induced hepatitis secondary to amiodarone and fluconazole. both were d/c'ed. there was improvement in the alt/ast but alkaline phosphatase remains elevated but slowly coming down. per hepatology, of remains elevated will consider mrcp. patient asymptomatic. . 10)arf. the patient's cr improved post blood transfusion and diuresis on presentation. possibly this was all secondary to increased blood volume with transfusion but could also be contribution of improved cardiac output with diuresis. although volume status even now, it is possible that he had been persistently positive as an outpatient. the patient's chf was optimized as above. his lisinopril was held. colchicine was dosed renally. the patient's cr hovered near his baseline. over the course of his hospital stay his creatinine slowly improved and is currently 1.4. . 11)hyponatremia. the patient was hyponatremic on presentation. this improved with diuresis despite even i/o's. this was felt most likely hypervolemic hyponatremia given improvement with diuresis. it was possibly due to fluid retention decreased effective arterial volume during chf exacerbation. supported by fe bun suggestive of prerenal azotemia. urine osmolality low likely secondary to volume overload or diuretics but does not suggest siadh. the patient's chf was managed as described above. . 12) swollen/painful r wrist, r knee and l 3rd digit on the hand. initially the patient presented with swelling and erythema of the r wrist. ddx included septic joint vs gout. xray of the wrist showed no fractures. there were noted changes c/w active gouty tophi. rheumatology was unable to obtain fluid by needle. hand plastics took the patient to the or for wash out. fluid from this procedure grossly had crystals and on gram stain revealed gram positive cocci in pairs and clusters consistent with infectious gouty joint. the patient's r knee was tapped multiple times and fluid revealed gouty crystals with low level staph aureus growth. the patient was diagnosed with polyarticular gout with overlying septic joints. the r wrist was washed out as described. the patient was continued on colchicine (dosed renally) and allopurinol. steroids were held due to bacteremia. for pain control the patient was given oxycodone sr (40, and then 60 ), percocet prn for breakthrough, and tylenol. the colchicine was d/c'ed due to worsening renal function. he was continued on allopurinol 300mg daily and tolerated well. patient did not complain of any pain during the remaining of his stay. . 13) l foot ulcers: s/p debridement. these appear consistent with tophaceous gout. white material extruding from ulcers that was diagnosed as uric acid by rheumatology on past admissions. was seen recently by who felt ulcers, which have been chronic, are improving. surgery wound care, rheumatology and podiatry were consulted. xray did not reveal any new erosions, though underlying osteo could not be excluded. swab culture results revealed mrsa at this site. podiatry removed stitches and wound nicely healing. daily wet-to-dry dressings and should remain in mp boots. . 14) chronic pain. for chronic and acute gouty pain, the patient received oxycontin , oxycodone for breakthrough and tylenol. patient found to be drowsy and less responsive with opioids. opioids were d/c'ed and patient was maintained on standing tylenol. . medications on admission: sotalol 120 mg mexilitine 150 mg tid allopurinol 200 mg qd asa 325 mg qd colchicine 0.6 mg qd 40 mg tid (increased from 1 month ago) lisinopril 5 mg qd oxycontin 40 mg sr plavix 75 mg qd pravachol 40 mg qd senna qhs discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 2. aspirin 81 mg tablet, chewable sig: two (2) tablet, chewable po daily (daily). 3. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 4. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily): please stop on . 5. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day): please stop on . 6. mexiletine 150 mg capsule sig: one (1) capsule po q8h (every 8 hours). 7. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 8. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed for pain/fever. 9. papain-urea unit-mg/g ointment sig: one (1) appl topical daily (daily). 10. becaplermin 0.01 % gel sig: one (1) appl topical daily (daily). 11. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 14. epoetin alfa 10,000 unit/ml solution sig: () units injection qmowefr (monday -wednesday-friday). 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 16. albuterol sulfate 0.083 % solution sig: one (1) puff inhalation q6h (every 6 hours) as needed. 17. ipratropium bromide 0.02 % solution sig: one (1) puff inhalation q6h (every 6 hours). 18. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 19. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 20. vancomycin 500 mg recon soln sig: seven y (750) units intravenous q48h (every 48 hours): please check vancomycin level in 2 days and then weekly. 21. procainamide 100 mg/ml solution sig: as directed injection prn as needed for stable vt: if having stable vt, please administer drip at 20 mg/min up to 17 mg/kg total dose and may notify on call ep fellow at . also try shock for unstable vt. . 22. fondaparinux 2.5 mg/0.5 ml syringe sig: one (1) injection subcutaneous once a day: until patient ambulating three times daily. hold day prior to ep study. discharge disposition: extended care facility: mt. nai discharge diagnosis: primary: mrsa bacteremia with seeding of pacemaker lead, ankle, knee recurrent stable ventricular tachycardia urinary retention: d/c'd foley with failed voiding trial transaminitis: renal failure from atn polyarticular gout intermittent confusion chronic pain decub ulcer secondary: coronary artery disease hypertension hyperlipidemia copd chronic lle ulcers pvd/claudication: s/p right external iliac artery stent , complicated by lue hematoma? nerve injury; right to left fem-fem bypass grafting in spinal stenosis bilateral renal masses discharge condition: stable. discharge instructions: 1)weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction to <1.5l/day . 2)take all medications as prescribed as indicated in discharge instruactions. . 3)attend all follow-up appointments. . 4)please fax weekly cbc, bun/cr, vancomycin trough to attention of dr. at the clinic at . . 5)please check vancomycin trough level in 2 days () and fax to dr. at . . 6)return to the emergency department or call your doctor for new fevers, chills or nightsweats, blurry vision, neck stiffness, worsening redness of the skin or redness, swelling of any joints. followup instructions: 1)follow up with ep - they should contact you for potential ep study procedure in weeks. 2)follow-up with dr. of orthopaedics 4 weeks from staple removal - 10:00a , clinic (sb) 09:40a x-ray ortho scc2 x-ray ortho scc2. 3)left dorsal foot (debrided on )and left heel ulcer, follow-up with dr. in podiatry clinic () 1 week after discharge. 02:30p podiatry, clinic (sb) 4)follow-up with the renal division () 4 weeks after discharge.provider: , m.d. phone: date/time: 2:30 5)outpatient follow-up for suppressive therapy at conclusion of vanc therapy (6 weeks after ), in clinic () with either dr. - you have an appointment on at 11 am ( basement). also, vancomycin results can be faxed to for dosing adjustments. procedure: venous catheterization, not elsewhere classified other endoscopy of small intestine diagnostic ultrasound of heart diagnostic ultrasound of heart excisional debridement of wound, infection, or burn arthrocentesis arthrocentesis transfusion of packed cells synovectomy, knee removal of lead(s) [electrode] without replacement other tenonectomy other arthrotomy, wrist revision or relocation of cardiac device pocket other local excision or destruction of lesion of joint, foot and toe diagnoses: anemia of other chronic disease congestive heart failure, unspecified acute kidney failure, unspecified hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified infection with microorganisms resistant to penicillins methicillin susceptible staphylococcus aureus septicemia chronic kidney disease, unspecified other specified cardiac dysrhythmias pressure ulcer, lower back anticoagulants causing adverse effects in therapeutic use hematemesis pressure ulcer, heel hepatitis, unspecified disruption of external operation (surgical) wound candidal esophagitis infection and inflammatory reaction due to cardiac device, implant, and graft cardiac rhythm regulators causing adverse effects in therapeutic use pyogenic arthritis, multiple sites 

Answer: The patient is high likely exposed to