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: a 52-year-old man, with coronary artery disease status post one-vessel cabg, mvr, congestive heart failure with ef 20-25%, who presents with increased dyspnea on exertion worsened over the last 2 days. he also reports increase in fatigue and anorexia over the last month with approximately a 10 pound weight loss. he initially describes the shortness of breath as intermittent and occurring over the last month, however significantly worsened over the last few days. he denies ever having any chest pain. he was evaluated by his primary cardiologist and electively admitted for right heart cath. on , the patient underwent right heart catheterization which showed cardiac output 4.13, cardiac index 2.33, pulmonary capillary wedge pressure 46, pa pressure 73/27. left heart catheterization was also performed which showed widely patent lima to lad with normal left main, occluded midvessel lad, midvessel 30% left circumflex lesion, and luminal irregularities in the rca. after the cardiac catheterization, he was admitted to the cardiac intensive care unit for tailored chf management. secondary to sedation received in the cardiac cath lab and increasing hypercapnia, the patient was electively intubated on . the patient was extubated on . however, due to fever to 103, right lower lobe infiltrate and respiratory distress, he was reintubated. over the course of the next 4 days, the patient was diuresed with natrecor for a short period of time, as well as intravenous lasix. his cardiac output and index progressively improved to a point where his cardiac output was roughly 6, and his index was 3.3. as his chf management was felt to be optimized, he was placed no pressure support ventilation on numerous occasions and was not deemed able to be weaned from the ventilator. he was, therefore, transferred to the medical intensive care unit for further respiratory management and possible tracheostomy. past medical history: 1. congestive heart failure with ef of 20-25%. 2. coronary artery disease status post cabg in , one-vessel, lima to lad. 3. status post mitral valve repair x 2 in and , with his last mvr being a st. jude valve secondary to significant staph endocarditis. 4. atrial fibrillation on coumadin. 5. type 2 diabetes. 6. duodenal ulcer with history of upper gi bleed. 7. endocarditis complicated by septic emboli. 8. restrictive lung disease thought secondary to ankylosing spondylitis. pfts in showed an fev1 of 1.62, fvc 2.51. pfts repeated in showed similar fev1 to fvc ratio with a total lung capacity of 48%. pfts in similarly showed an fev1 of 1.39 and fvc of 1.56. 9. history of varicose veins. 10.clinically diagnosed ankylosing spondylitis, however no official diagnosis. 11.history of brain abscesses secondary to septic emboli from endocarditis. 12.history of gout. 13.history of left lower extremity cellulitis, hospitalized in . family medical history: significant for coronary artery disease, as well as other family members with mvr and . allergies: no known drug allergies. social history: no current tobacco or alcohol use. remote smoking history, quit 20 years ago. home medications: 1. digoxin 0.125 mg po qd. 2. carvedilol 6.25 mg po bid. 3. glyburide 10 mg q am 4. rosiglitazone 2 mg q am. 5. lisinopril 10 mg qd. 6. allopurinol 100 mg qd. 7. bumex 2 mg qd. 8. coumadin 3 mg/4 mg alternating qod. physical examination on transfer to the medical intensive care unit on (unfortunately, there is no admission note available at this time.): temperature 99.3, blood pressure 91/46, heart rate 77-95, pulmonary artery pressure 53/21, pulmonary capillary wedge pressure 12, cvp 12, ventilated on assist control 500x10, peep of 5, fio2 30% with sao2 of 98-100%. in general, the patient was intubated and sedated. heent exam: pupils were equal, round and reactive. sclerae were anicteric. et tube and og tube were in place. neck: demonstrated a right internal jugular cordis which was in place which was clean, dry and intact. there was a hematoma tracking into the right scapular area secondary to traumatic line placement. thorax: demonstrated limited chest wall movement with inspiration. bilateral rhonchi were noted. there was a question of paradoxical movement of the chest wall. cardiovascular examination: an irregularly irregular heart rate, loud metallic s2, with a iii/vi systolic murmur diffusely across the precordium. abdomen: tense but there was no rebound or guarding. normoactive bowel sounds. extremities: showed chronic venous stasis changes bilateral lower extremities, but there was no edema on exam. he had decreased peripheral pulses bilaterally, which have been noted to be dopplerable in the past. skin: demonstrated no other rashes or skin breakdown. there were no sacral decubitus ulcers. neuro exam: he was awake and alert, and he was following commands appropriately once sedation was weaned. laboratory values on : white count 12.0 with normal differential, hematocrit at baseline 39 which decreased to 29, platelets 108, mcv 89, pt 12, inr 1.1, ptt 58, sodium 139, potassium 3.8, chloride 98, bicarb 33, bun 24, creatinine 0.8, glucose 110, calcium 8.3, phosphorus 3.4, magnesium 2.3, alt 14, ast 33, alk phos 62, total bili 1.4, hemoglobin a1c 9.0. blood cultures and were negative. sputum culture from showed 4+ gram-positive cocci in pairs, chains and clusters. however, respiratory culture showed only moderate growth of oropharyngeal flora. ekg from on admission showed atrial fibrillation, poor r wave progression, low voltage, but essentially unchanged from ekg dated . pertinent radiographic examinations during hospital course: 1. ct of the abdomen showed diffuse bibasilar central lobular and nodular pulmonary opacities likely consistent with infectious etiology. simple cyst within the right kidney. no evidence of bowel obstruction, perforation, or an abscess within the abdomen. 2. chest x-ray showed improving right lower lobe process related to area of resolving aspiration or pneumonia. 3. transthoracic echocardiogram showed an ef of 25%, left atrial enlargement, global left ventricular hypokinesis, paradoxical septal motion consistent with right ventricular pressure volume overload, and increased pulmonary hypertension when compared with transthoracic echocardiogram performed in . 4. cardiac catheterization showed cardiac output 4.13, cardiac index 2.33, pa pressure 73/27, pulmonary capillary wedge pressure mean of 46. there was a widely patent lima to lad with the left main showing no angiographically apparent lesion. his lad was occluded midvessel. there was a left circumflex midvessel lesion of approximately 30%. rca demonstrated luminal irregularities. impression: a 52-year-old,with congestive heart failure, ef of 20-25%, coronary artery disease status post one-vessel cabg in , mvr x 2 complicated, first one complicated by endocarditis with current st. jude valve, atrial fibrillation, and restrictive lung disease known to be present since which is thought secondary to ankylosing spondylitis, who was transferred from the cardiac intensive care unit to the medical intensive care unit for difficulty to wean from the ventilator despite optimal diuresis. hospital course - 1) respiratory failure: the patient's initial presenting symptoms included dyspnea on exertion and shortness of breath for 1 month which increased over the last 2 days. however, his symptoms also included significant fatigue, anorexia and a 10-pound weight loss. given his clinical history and chest x-ray findings, he was felt to have a right lower lobe pneumonia which, in combination with congestive heart failure, was contributing to his symptoms at home. however, postcatheterization on , the patient was noted to be overly sedated secondary to medications received in the cardiac catheterization lab, and had an abg performed. the gas at that time showed a ph of 7.12, pco2 96, po2 103. it was unclear what the patient's baseline pco2 was; however, it was suspected to be elevated given his history of restrictive lung disease and likely poor ventilatory ability. the patient was extubated on with immediate postextubation abg showing ph 7.31, pco2 74, po2 154 which, over the next few hours, worsened to abg with ph 7.20, pco2 95, po2 93. he was reintubated for hypercapnic respiratory failure a few hours after initial extubation. he was tried on pressure support ventilation over the next 48 hours and failed multiple weaning trials. he was, therefore, transferred to the medical intensive care unit , after being intubated 4 days and deemed unable to wean from the ventilator. it was the opinion of the medical intensive care unit team that the patient's primary respiratory difficulties were secondary to restrictive lung disease, which acutely worsened secondary to a right lower lobe pneumonia. he was treated with intravenous antibiotics for a total of 14 days with improvement in the right lower lobe pneumonia. numerous trials were performed in hopes of extubating the patient. however, at the time of this dictation, the patient's rsbi still remained greater than 100, and he is currently on pressure support ventilation of 20/5. he has been weaned down on numerous occasions to pressure support ventilation of . he currently is off all sedation and appears to be breathing comfortably without signs of respiratory distress. of note, his tidal volumes are approximately 200-300 with respiratory rates in the mid to high 20s. a vd/vt was performed while still intubated which showed a percentage greater than 60. it was likely felt secondary to the amount of dead space, and that he would be unlikely to tolerate extubation, and plans were still in place for a tracheostomy. due to his chronic restrictive lung disease, it was felt that his baseline pco2 ran in the range of 50-60, and his po2 was adequate in the 80-90 range. his vent settings were titrated for these goals, and the patient had no apparent respiratory distress. 2) congestive heart failure: mr. was initially admitted with symptoms which appeared to be consistent with congestive heart failure exacerbation over the last month. at the time of admission, his pulmonary capillary wedge pressure was 46. he was diuresed appropriately with lasix and natrecor down to a pulmonary capillary wedge pressure of 14. however, at this time he appeared to be volume deplete, and he was given intermittent intravenous fluid boluses until his hemodynamics were optimized. he appeared to be optimized with a capillary wedge pressure of approximately 22, and a cvp in the 12-14 range. with these settings, his cardiac output was 6.0, and his cardiac index was 3.3. his swan was pulled on . attempts to restart his outpatient chf management, including ace inhibitor and lasix, was attempted. however, the patient dropped his pressure to these interventions. per his outpatient cardiologist, dr. , these medications were placed on hold until he was stable off the ventilator. he was continued on his digoxin 0.25 mg qd with normal dig levels maintained. 3) infectious disease: he was found to have a right lower lobe infiltrate on chest x-ray, and a sputum culture with gram-positive cocci, 4+, in pairs and clusters. it was assumed that he had a staph pneumonia and was appropriately treated with vancomycin and ceftriaxone for plans to complete a 14-day course. he received an additional 5 days of azithromycin at the beginning of his course. blood cultures were performed on 2 separate occasions and found to be no growth both times. 4) acute renal failure: on two separate occasions, mr. creatinine bumped with diuresis. urine electrolytes were performed, and on each occasion showed evidence of prerenal physiology. lasix was held, and he was given mild hydration with improvement in creatinine. 5) mitral valve replacement: he is status post mvr x 2, currently with a st. , well-seated per transthoracic echocardiogram . after cardiac catheterization, he was maintained on a heparin drip with a goal ptt of approximately 60-80. coumadin is planned to be started after the patient's tracheostomy. 6) arrhythmia: the patient known to be in chronic afib. however, he had a few episodes of nsvt ranging from 10-17 beats while he was on levophed. as he was felt to have nonischemic cardiomyopathy, there was no role for antiarrhythmic therapy or icd placement. once he was discontinued from pressor therapy, his nsvt resolved. 7) anemia: mr. baseline creatinine is approximately 39, which dropped to 29 over the first few days in the intensive care unit. it was felt that his anemia was secondary to blood loss, as he had a traumatic right intrajugular central line placed with surrounding ecchymoses/hematoma. he was transfused on several occasions to maintain his hematocrit above 30. he tolerated these transfusions without incident. his neck hematoma appeared to be improving at the time of this dictation and it was likely that his heparin use contributed to this process. 8) rheumatology: due to the confusion over the patient's diagnosis of ankylosing spondylitis, the rheumatology service was consulted. per their request, an hla-b27 level was sent which was found to be negative. using this information, they felt that his most likely diagnosis was dish and; therefore, his intercept was discontinued. 9) fen: the patient was on tube feeds, probalance, at a goal rate of 65 cc/h while an og tube was placed. a peg tube will be placed after tracheostomy, and continue tube feeding as appropriate. disposition: mr. will remain in the medical intensive care unit until tracheostomy is performed, at which time screening for a pulmonary rehabilitation facility will take place. discharge diagnoses: 1. restrictive lung disease secondary to abnormal chest wall compliance secondary to diffuse idiopathic skeletal hyperostosis (dish). 2. respiratory failure requiring prolonged intubation. 3. right lower lobe pneumonia thought secondary to staphylococcus aureus. 4. congestive heart failure, systolic, nonischemic. 5. acute renal failure, prerenal in etiology. 6. atrial fibrillation. 7. nonsustained ventricular tachycardia. 8. type 2 diabetes. 9. chronic atrial fibrillation. discharge medications: to be dictated in discharge summary addendum. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for 96 consecutive hours or more combined right and left heart cardiac catheterization coronary arteriography using two catheters parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy arteriography of other intra-abdominal arteries transfusion of packed cells injection or infusion of nesiritide diagnoses: acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified septicemia paroxysmal ventricular tachycardia hemorrhage complicating a procedure acute and chronic respiratory failure pneumonitis due to inhalation of food or vomitus pneumonia due to staphylococcus, unspecified postinflammatory pulmonary fibrosis 

Answer: The patient is high likely exposed to