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 / sulfa (sulfonamides) / heparin agents attending: chief complaint: fatigue/doe/chest pain major surgical or invasive procedure: - 1) cabgx6 (left internal mammary->left anterior descending artery, saphenous vein graft (svg)->diagonal artery, svg->obtuse marginal first and second artery, svg->posterior descending and posterior lateral branch. 2) aortic valve replacement (19mm ce magna tissue). 3) ascending aorta replacement (24mm gelweave graft). re-exploration for bleeding - embolectomy of upper right extremity expl. lap/cholecystectomy/g-j tube placement tracheostomy history of present illness: ms. is a very nice 77-year-old female with a known history of aortic stenosis, which has been followed by serial electrocardiograms who was found to have severe left main and three-vessel disease during a cardiac workup prior to elective breast surgery. this workup also revealed a very heavily calcified ascending aorta. given these findings, she was deferred surgery in due to her elevated risk. currently, she complains of significant fatigue, dyspnea on exertion, and occasional chest pain. she now presents to me for surgical evaluation for her aortic valve and her coronary artery disease. a cardiac catheterization from showed a right dominant system with 80% left main coronary artery stenosis, 90% stenosed left anterior descending artery, 80% stenosed diagonal artery, 90% stenosed left circumflex artery, 90% right coronary artery stenosis, and an 80% posterior descending artery stenosis. the ejection fraction is 70%. she has no mitral regurgitation and her aortic valve area is calculated at 0.7 cm2. an echocardiogram from showed severe aortic stenosis with an aortic valve area mean of 61 mmhg, mild aortic insufficiency, trace mitral regurgitation, mild tricuspid regurgitation, and ejection fraction of 75%. past medical history: past medical history is notable for aortic stenosis, coronary artery disease, hypertension, hyperlipidemia, and a breast mass which was recently biopsied and found to be negative for malignancy, basal cell skin cancer on her back, and breast cancer status post her right mastectomy in . other than the biopsy and mastectomy, there is no significant surgical history. social history: currently, she is retired. she is a nonsmoker. she occasionally drinks alcohol. she has full dentures. she lives with her friend in , . family history: her family history is remarkable for a brother who had an mi at the age 62 with her mother and father both also having coronary artery disease. physical exam: admission hr 84 and regular. rr 14. bp rt arm is deferred d/t mastectomy. on left 158/62. ht 5'4" wt 144 lbs. gen well-developed and well-nourished elderly female who is somewhat anxious and tearful. skin is warm and dry without clubbing or cyanosis. she has a well-healed right mastectomy scar. heent examination shows her to be normocephalic and atraumatic. pupils are equal, round, and reactive to light. sclerae are anicteric and oropharynx is benign. her neck is supple with full range of motion and no jvd. her lungs show mild decrease in breath sounds at the left base but otherwise clear. her heart shows a regular rate and rhythm without a iv/vi very loud and harsh systolic ejection murmur. her abdomen is soft, nondistended, and nontender with normoactive bowel sounds. extremities are warm and well perfused with 1+ bilateral lower extremity edema. she has positive varicosities noted on her left thigh and left lower extremity as well as her right lower extremity. neurologic exam, she is alert and oriented x3 without any focal deficits. pulses in her femoral are 2+ bilaterally, dp is 1+ bilaterally, pt is 1+ bilaterally,, and radial is 2+ bilaterally. there is a bruit versus transmitted murmur heard over both her carotid arteries. discharge vs t 99 hr 88 sr bp 155/58 rr 28 o2sat 100% 50% trach collar gen trached, nad neuro alert-responsive-interactive, follows commands pulm diminished in bases l>r cv rrr, no murmur. sternum stable, incision cdi abdm soft, nt. g-j tube site cdi. midline incision w/vac, clean margins ext left foot w/necrotic areas of distal toes. rt bka, flap w/staples-cdi tld trach, g-j tube, foley, left arm picc pertinent results: 07:02pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 07:49pm pt-12.1 ptt-29.1 inr(pt)-1.0 07:49pm plt count-259 07:49pm wbc-6.1 rbc-3.55* hgb-10.6* hct-31.7* mcv-89 mch-29.9 mchc-33.5 rdw-14.6 07:49pm alt(sgpt)-14 ast(sgot)-17 ld(ldh)-173 alk phos-88 amylase-67 tot bili-0.2 07:49pm glucose-138* urea n-22* creat-1.3* sodium-145 potassium-4.3 chloride-105 total co2-30 anion gap-14 02:39am blood wbc-12.6* rbc-3.67* hgb-10.6* hct-32.7* mcv-89 mch-28.9 mchc-32.4 rdw-20.3* plt ct-206 02:39am blood plt ct-206 02:39am blood pt-25.8* ptt-33.4 inr(pt)-2.6* 02:39am blood glucose-135* urean-66* creat-1.2* na-144 k-4.3 cl-114* hco3-24 angap-10 02:41am blood alt-29 ast-29 alkphos-152* totbili-0.9 06:04pm blood lipase-33 07:49pm blood %hba1c-6.2* 11:01am blood tsh-9.0* chest ct 1. marked ascending aortic calcification, with less extensive calcifications in the descending aorta 2.right apical fibrosis, traction bronchiectasis and volume loss. given calcified component and granulomas within the lungs, sequela of prior granulomatous disease is the most likely etiology, although prior radiation therapy may also be a contributing factor. 3. probable minimal subpleural basilar fibrosis. differential diagnosis would include nsip or early uip. recommend correlation with pulmonary functio4/16/08 . n tests if warranted clinically. lung findings could also be confirmed and further characterized with prone hrct, if warranted clinically. 4. coronary artery calcifications. 5. findings suggestive of recent intervention within the left breast. please correlate with clinical history. vein mapping duplex evaluation was performed of bilateral lower extremity veins. the greater saphenous veins are patent from the groin to the ankle bilaterally. on the right, vein diameters range from 0.28-0.72. on the left, vein diameters range from 0.24-0.53 cm. carotid ultrasound bilateral less than 40% carotid stenosis. cxr calcified right apical pleural thickening is better assessed on ct from earlier today. no evidence of pneumonia or chf. echo prebypass 1. mild spontaneous echo contrast is present in the left atrial appendage. a left-to-right shunt across the interatrial septum is seen at rest. a small secundum atrial septal defect is present. 2.there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. there are complex (>4mm) atheroma in the ascending aorta. there are complex (>4mm) atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. 5.the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (area <0.8cm2). mild (1+) aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. dr. was notified in person of the results on at 800am. post bypass 1. patient was being av paced and subsequently in sinus rhythm. 2. biventricular systolic function is unchanged. 3. bioprosthetic valve seen in the aortic postion. leaflets move well and the valve appears well seated. trace to mild aortic sufficiency present. 4. there was systolic anterior motion of the mitral valve associated with moderate mitral regurgitation that resolved with administration of volume and reducing the heart rate as well as myocardial contractility. 5. atrial septal defect is present with bidirectional flow. 6. patient brought back to the or for bleeding immediately after entering the icu. 7. biventricular function is unchanged. 8. small pericardial effusion. no evidence of tamponade. 9. small clot seen in the left atrium attached to the coumadin ridge. dr made aware. no action to be taken. echo 1) a 1cm x 1cm homogenous echodensity seen attached to the tip of the coumadin ridge with a lot of mobility. 2) there is a similar 1cm x 0.5 cm homogenous echodensity seen on the atrial aspect of the interatrial septum with no mobility. 3) there are 2 distinct 1cm x 1cm homogenous echodensity seen in the distal aortic arch close to the left sublclavian and mid thoracic aorta (35cm of the incisors) which are freely mobile. 4) a ragged edge of the thoracic aorta is seen. 5) preserved biventricular systolic functon. 6) the lv cavity is small with chordal and no resting gradients at this point of time (hr 56/min). 7) moderate tricuspid regurgitation and mild mitral regurgitation. 8) aortic prosthesis seems entirely normal. 9) there is a right to left interatrial shunt as noted before. comment: compared to the previous tee on at 8pm, there are new clots in the interatrial septum and possibly in the thoracic aorta. radiology final report mri abdomen w/o contrast 2:47 pm mri abdomen w/o contrast reason: assess for stenosis/ medical condition: 77 year old woman s/p asc ao replacement/avr/cabg w/hot symptoms reason for this examination: assess for stenosis/thrombus-flow contraindications for iv contrast: acute renal failure mri abdomen indication: ascending aorta replacement/aortic valve replacement/coronary artery bypass graft. possible hit. assess for stenosis or thrombus in renal arteries or veins. technique: multiplanar t1- and t2-weighted imaging was performed through the renal vasculature. intravenous contrast could not be administered in view of renal impairment. breath-hold independent imaging was performed as suspension of respiration with the available ventilator equipment was not possible. strategies to evaluate the vasculature without gadolinium including time-of- flight imaging and fiesta sequences were employed. comparison: renal ultrasound, . findings: the renal veins are patent bilaterally. the renal arteries are not adequately assessed as the study had to be performed independent of breath holding. some flow in the right renal artery is demonstrated, but the renal arteries are incompletely assessed. there is generalized anasarca with extensive subcutaneous edema. there is ascites. there is a large right pleural effusion. there is a small left pleural effusion or left basal pulmonary airspace infiltration. there is a left renal upper pole cyst measuring 1.1 cm in diameter. the left kidney measures 9.8 cm in diameter. the right kidney measures 8.7 cm in diameter. limited assessment of the pancreas is within normal limits. no significantly sized focal liver lesions are detected. there is a 2.7 cm area of high signal at the inferior aspect of the left breast, likely representing a seroma as a sequelae of previous biopsy (documented on careweb notes). impression: 1. limited study demonstrating patency of bilateral renal veins. 2. renal arteries not adequately assessed. 3. generalized subcutaneous edema, ascites, and large right pleural effusion. 4. small left pleural effusion and left basal pulmonary airspace opacification. 5. seroma at inferior aspect of left breast, likely representing sequelae of previous biopsy. 6. left renal cyst. the study and the report were reviewed by the staff radiologist. dr. dr. approved: fri 1:49 pm radiology final report chest (portable ap) 11:15 am chest (portable ap) reason: ? infiltrate medical condition: 77 year old woman with s/p avr reason for this examination: ? infiltrate history: cardiac surgery, for comparison. findings: in comparison with the study of , there is little change in the appearance of the cardiomediastinal silhouette. bibasilar atelectasis is seen. there is more haziness in the left hemithorax, raising the possibility of some increasing pleural fluid. the right lung remains essentially clear. dr. radiology final report picc w/o port 4:29 pm reason: please evaluate for picc needs antibiotics hx of thrombosis medical condition: 77 year old woman with s/p asc aorta replacement reason for this examination: please evaluate for picc needs antibiotics hx of thrombosis and rt embolectomy please call with questions - please evaluate flow prior to insertion - call with questions thanks picc line placement indication: iv access needed for antibiotics. history of subclavian thrombosis and hitt. the procedure was explained to the patient. a timeout was performed. radiologist: dr. and performed the procedure. dr. the attending radiologist, was present and supervised the entire procedure. technique: using sterile technique and local anesthesia, the left basilic vein was punctured under direct ultrasound guidance using a micropuncture set. hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. a peel-away sheath was then placed over a guidewire and 10 ml of optiray was injected for a limited venogram demostrating occlusion of the left brachiocephalic vein just distal to the confluence of the left sublavian and left internal jugular vein with collateral vessel formation. line measuring 56 cm in length was then placed through the peel- away sheath with its tip positioned in the left brachiocephalic vein near the clavicular head proximal to the occlusion with fluoroscopic guidance. position of the catheter was confirmed by a fluoroscopic spot film of the chest. the peel-away sheath and guidewire were then removed. the catheter was secured to the skin, flushed, and a sterile dressing applied. the patient tolerated the procedure well. there were no immediate complications. impression: ultrasound and fluoroscopically guided line placement via the left basilic vein. final internal length is 32 cm, with the tip positioned in the distal subclavian/proximal left brachiocephalic vein. limited venogram demonstrating occlusion of the left brachiocephalic vein proximally with collateral vessel formation. the study and the report were reviewed by the staff radiologist. dr. dr. brief hospital course: mrs. was admitted to the on for surgical management of her aortic valve and coronary artery disease. she was worked-up in the usual preoperative manner including a carotid duplex ultrasound whisch showed less then 40% stenosis of her bilateral internal carotid arteries. vein mapping was also obtained which showed a dilated but usuable bilateral greater saphenous vein. a ct scan was also performed to evaluate her aortic calcification which revealed marked ascending aortic calcification, with less extensive calcifications in the descending aorta. on , ms. was taken to the operating room where she underwent coronary artery bypass grafting to six , aortic valve replacement with a tissue bioprosthesis and replacement of her ascending aorta. please see operative note for details. postoperatively she was transferred to the intensive care unit for monitoring. as her chest tube output was high, she was promptly returned to the operating room where she underwent a re-exploration for bleeding. hemostasis was acheived. please see separate dictated operative note for details. she was again transferred to to the intensive care unit. pressors were slowly weaned off. amiodarone was started for atrial fibrillation. on postoperative day 3, she awoke neurologically intact and was extubated. she was pancultured for leukocytosis and vancomycin, cefepime and flagyl were started. on postoperative day four, she was reintubated for acidosis and respiratory distress. she was noted to have an ischemic right hand and the vascular surgery service was consulted. an emergent embolectomy was performed of her right brachial, radial and ulnar arteries with good result. thrombus was noted in the aorta and embolism was noted of all 4 extremities. argatroban was started as hit was suspected however an initial hit antibody was negative. she was however thrombocytopenic. the hematology service was consulted who performed further studies to rule out a hypercoagulable state. increased levels of ldh and nucleated red cells were noted on a peripheral blood smear. coumadin was held. sputum showed pseudomonas and levaquin was added to cefepime. renal consult obtained on pod #10. head ct negative on for obvious stroke. hit serotonin assy negative, but argatroban continued for hypercoagulable symptoms with continuing necrosis of distal digits. coumadin restarted.hematology consult also done. evaluated for an acute abdomen on and taken to or by dr. for exploratory lap/cholecystectomy and g-j tube placement.lupus panel also was negative. maroon-colored stools noted on and gi consult done. argatroban held. elevated inr negated endoscopy at that time.diuresis continued. trach performed by dr. on pod #19. wound care nurse d for blistering. apex and mid-abdominal incision opened for evacuation of pus at bedside on . argatroban restarted and started on coumadin. vac dressing with white foam first and then black foam was placed to her abdominal wound on . she tolerated 40 mintues of trach collar on . she was seen by podiatry for her ble gangrene and conservative therapy was recommended until the lesions demarcated. she was seen by plastic surgery for her necrotic fingers, and no intervention was recommended, the fingers will auto-necrose and auto-amputate. she continued with adaptic dressing changes to her toes. as she became more alert it was determined that she had almost complete hearing loss. she had bilateral pleural effusions and awaited subtherapeutic inr prior to undergoing thoracentesis on and 15. blood and wound cultures were positive for bacteroides and she was seen by infectious disease and she continued on cefepime for mssa (vanco and cipro dc'd) and pseudomonas in sputum and was started on falgyl for the bacteroides. she was also started on fluconazole for in wound cultures. on she underwent a right bka with vascular surgery. they also recommended accuzyme to her foot ulcer and knee immobilizer to bka stump. argatroban and coumadin were restarted the following day. she continued on trach collar trials during the day and vent support at night. courses of diflucan and cefepime completed on . passy muir valve was placed on , and she tolerated it for 10 minutes. ent consult is recommended to evaluate vocal cords given that she was unable to produce voicing with the valve in place. follow up speech and swallow evaluation and treatment are also recommended. on wbc rose and tlc was discontinued, and she was pancultured. inr was 4.1 and argatroban was dc'd, coumadin continued. urine culture grew yeast and sputum grew gram negatives and she was started on fluconazole and zosyn. zosyn was switched to cefepime and levofloxacin for pseudomonas. wbc improved. she developed melanotic stools, was started on ppi and was seen by gi. she was transfused, and coumadin was held. she was managed conservatively given medical issues and need for anticoagulation. melena continued to decrease, and hct stabilized. cefepime changed to ceftazidime on due to resistance. midline was placed on . vac was last changed on . medications on admission: lisinopril 20 mg once daily, crestor 5 mg once daily, imdur 60 mg once daily, metoprolol 100 mg once daily, clonidine 0.1 mg as needed, aspirin 325 mg once daily, xanax 0.25 mg as needed, multivitamins, fish oil, calcium with vitamin d, plavix 75 mg once daily, lexapro 10 mg once daily. discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 2. ascorbic acid 90 mg/ml drops sig: one (1) po daily (daily). 3. ferrous sulfate 300 mg/5 ml liquid sig: one (1) po daily (daily). 4. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 7. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 8. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: five (5) ml po q6h (every 6 hours) as needed. 9. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q6h (every 6 hours) as needed. 10. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 12. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed). 13. papain-urea 830,000-10 unit/g-% ointment sig: one (1) appl topical (2 times a day). 14. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal prn (as needed). 15. insulin glargine 100 unit/ml solution sig: twenty five (25) subcutaneous breakfast (breakfast). 16. pantoprazole 40 mg iv q12h 17. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 18. warfarin 1 mg tablet sig: dose adjusted to inr tablet po daily (daily): target inr 2-2.5 restart after inr<2.0. 19. ceftazidime 2 gram recon soln sig: two (2) gm injection q12h (every 12 hours) for 2 weeks. 20. levofloxacin in d5w 500 mg/100 ml piggyback sig: five hundred (500) mg intravenous q24h (every 24 hours) for 2 weeks. discharge disposition: extended care facility: & rehab center - discharge diagnosis: as/cad s/p cabg/ascending aorta replacement/aortic valve replacement hyperlipidemia htn aortic thrombus with limb emboli acute renal failure left benign breast mass basal cell skin cancer right breast cancer s/p mastectomy discharge condition: stable discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks 6) no driving for 1 month. 7) call with any questions or concerns. followup instructions: follow-up with dr. in 1 month. ( follow-up with dr. in weeks. follow-up with dr. in 2 weeks. follow-up with dr. (surgery) in 4 weeks please call all providers for appointments. md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified single internal mammary-coronary artery bypass extracorporeal circulation auxiliary to open heart surgery other enterostomy diagnostic ultrasound of heart diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances hemodialysis (aorto)coronary bypass of four or more coronary arteries venous catheterization for renal dialysis thoracentesis cholecystectomy reopening of recent thoracotomy site temporary tracheostomy open and other replacement of aortic valve with tissue graft resection of vessel with replacement, thoracic vessels other incision with drainage of skin and subcutaneous tissue other amputation below knee incision of vessel, upper limb vessels injection or infusion of nesiritide diagnoses: other iatrogenic hypotension coronary atherosclerosis of native coronary artery intermediate coronary syndrome acute kidney failure with lesion of tubular necrosis other postoperative infection cellulitis and abscess of trunk congestive heart failure, unspecified unspecified essential hypertension acute and subacute necrosis of liver atherosclerosis of aorta atrial fibrillation aortic valve disorders hemorrhage complicating a procedure other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonia due to pseudomonas bacteremia peripheral vascular complications, not elsewhere classified blood in stool unspecified hearing loss methicillin susceptible pneumonia due to staphylococcus aureus other and unspecified coagulation defects arterial embolism and thrombosis of lower extremity gangrene other suppurative peritonitis acute and chronic cholecystitis arterial embolism and thrombosis of upper extremity bacteroides fragilis perforation of gallbladder 

Answer: The patient is high likely exposed to