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: mr. is a 49 year old male with a history of diabetes, coronary artery disease and congestive heart failure who woke up approximately five hours prior to admission with shortness of breath, slight chest pressure and drove himself to the emergency department. there he was found to be in atrial fibrillation with ischemic changes and hypotension. he was noted to have a history of coronary artery disease but has not had any significant chest pain for the past few years, ever since the last catheterization. in the emergency department the patient was complaining of palpitations, decreasing shortness of breath along with chest and shoulder pain. past medical history: 1. coronary artery disease, status post myocardial infarction, status post percutaneous transluminal coronary angioplasty in , recent stress test in demonstrates no arrhythmia or electrocardiogram changes but his treadmill test was stopped for leg fatigue. his echocardiogram revealed some concentric hypertrophy and an ejection fraction of 55-50%. 2. insulin dependent diabetes mellitus. 3. hypercholesterolemia. 4. status post thyroidectomy for goiter with resultant hypothyroidism. medications on admission: 1. lipitor 40 mg p.o. q. day 2. lasix 40 mg alternating with 60 mg q.d. 3. folic acid 1 mg q.d. 4. synthroid 300 mcg q.d. 5. 70/30 insulin 70 units in the morning and 35 units in the evening allergies: demerol and percocet make him nauseated. physical examination: he is noted to be an obese middle-aged male in mild to moderate respiratory distress on a stretcher. his neck has 15 cm of jugulovenous distension and positive hepatojugular reflux but there is no bruit. his lungs have bilateral crackles at the bases, greater on the right then on the left. his heart is irregular with an s1 and s2 and a questionable s3. his abdomen is obese with normoactive bowel sounds. extremities have 3+ bilateral pitting edema. laboratory data: admission laboratory data reveals his white blood count is 6.6, hematocrit 36.2, platelets 120. sodium is 135, potassium 4.2, chloride 94, bicarbonate 31, bun 21, creatinine 1.2 and glucose 408. coagulation screen are normal. ck is 81, mb is 5, troponin is 2.0. electrocardiogram demonstrates atrial flutter at a rate of 138, there are q waves in leads v2 through v4. chest x-ray shows marked cardiomegaly with pulmonary congestion. recent laboratory studies reveal tsh 85, hemoglobin a1c 13.7. hospital course: this patient had an extremely long difficult complicated and drawn out hospitalization. the following is a very brief summary of events. the patient was found to have an acute myocardial infarction when he presented to the emergency room. he was in rapid atrial fibrillation and became hypotensive. due to his cardiogenic shock cardiothoracic surgery was consulted to place a balloon pump in him. he was stabilized on pressors over the course of the next several days. he was initially felt to be a poor candidate for revascularization but was eventually taken for surgery when he developed continued unstable angina. he had coronary artery bypass surgery times four on . his postoperative course was complicated by an acute left hemothorax requiring re-exploration, respiratory failure with failed extubation times three, paralyzed left hemidiaphragm, status post trach and percutaneous endoscopic gastrostomy, multiple episodes of rapid atrial fibrillation, worsening congestive heart failure and left upper extremity weakness secondary to a possible cortical or subcortical stroke. the following is a summary of the patient's operations: 1. , coronary artery bypass graft times four, his grafts are left internal mammary artery to left anterior descending, saphenous vein graft to pl, saphenous vein graft to ramus and saphenous vein graft to diagonal. 2. , mediastinal and left hemithorax exploration for bleeding. 3. , tracheostomy and percutaneous gastrostomy placement. the remainder of the patient's hospitalization is dictated by systems: cardiovascular - the patient presented to the emergency department in rapid atrial flutter. he progressively developed hypotension and required synchronise cardioversion. he was admitted to the cardiology service. cardiothoracic surgery was consulted to place an intra-aortic balloon pump in him. he stabilized over the course of several days. initially it was felt that the patient was not an operative candidate and would instead be best suited to have several months of medical management after which time perhaps he would be a better candidate for revascularization. during his hospitalization he developed continued chest pain, requiring nitroglycerin and heparin drip. for this reason, despite the patient's high risk status, he agreed to go ahead with surgery. on the patient went to the operating room for coronary artery bypass graft times four as described above. the procedure itself was unremarkable. he was transported intubated to the cardiac surgery intensive care unit on propofol, milrinone, levophed and aprotinin drips. the following day he was found to have developed an acute left hemothorax that required a return trip to the operating room. while there he had a mediastinal and left hemithorax exploration. the patient returned to the cardiac surgery intensive care unit intubated on milrinone, propofol and levophed drips. the following day, during his first failed extubation he developed rapid atrial fibrillation. during the next 18 days he spent in the intensive care unit he had repeated episodes of rapid atrial fibrillation that required loading with intravenous amiodarone. after about seven or eight days many of his pressors were able to be weaned off and he required only an amiodarone drip. soon lasix drips were added to aid with his diuresis as he developed a metabolic acidosis. diamox was also added. an electrophysiology consult was obtained for input as how to best manage his atrial fibrillation. they felt that his paroxysmal atrial fibrillation and hypotension may actually be due to overdiuresis and intravascular volume depletion. in addition they were suspicious that perhaps the patient's thyroid status may be contributing to this. he had a transthoracic echocardiogram that demonstrated an ejection fraction of approximately 30% in addition to severely depressed left ventricular systolic function and severe left ventricular hypokinesis around the time he was started on a heparin drip to anticoagulate him. eventually he remained in a sinus rhythm or sinus tachycardia and did not have a recurrence of his arrhythmia. before he left the intensive care unit he was loaded orally with amiodarone 400 mg three times a day. in addition he was kept on lopressor 25 mg twice a day. once the patient came to the floor a consult was obtained from the congestive heart failure service. they initially thought he would benefit from an ace inhibitor and also required more diuresis as he had a prominent amount of jugulovenous distension and continued to have 3+ pitting edema of his lower legs. their recommendation initially was to start him on an ace inhibitor, diurese him more and eventually increase the dose of his beta blocker after his total body volume has been decreased. however, the patient became mildly hypotensive on initial attempts to dose him with captopril. in addition he had some transient rises in his creatinine with intravenous lasix. it was unclear at the time whether or not this was due to the medication or fluid intake. regardless, multiple small changes had to be made in his regimen. ultimately by the time of his discharge he had been on lasix 80 mg intravenously b.i.d. and this was converted to bumex 3 mg b.i.d. p.o. in addition he was started on a very low dose of zestril at 2.5 mg p.o. q. day and his amiodarone and lopressor were continued. ultimately on this regimen he was able to maintain a blood pressure of approximately 100 to 110 systolic and his heartrate remained in the 100 to 105 range which was an improvement from the chronic sinus tachycardiac rate of 115 to 118 that he had been in previously. as the patient will be followed as an outpatient in congestive heart failure clinic here at under the supervision of dr. , office #. pulmonary - the patient was intubated at the time of his initial operation. on the second postoperative day after his successful exploration for hemithorax and placement of the left chest tube, the patient had his first attempt at extubation. within the hour he had to be emergently reintubated. he was given several days to wean off of the ventilator and on postoperative day #11 a second attempt was made to extubate him. he promptly desaturated into the 70s and again required reintubation. finally on the 16th postoperative day he had a final attempt at extubation that also failed and required reintubation. this prompted an ultrasound of the chest that demonstrated left diaphragmatic paralysis. the decision was made to place a trach in this patient to facilitate his ventilator wean. on , the patient had a tracheostomy performed by dr. . over the next three days the patient was slowly weaned to a trach collar and by a full three days later was no longer ventilator dependent. he was transferred to the floor on which was his 22nd postoperative day. there he was evaluated by the speech and swallow team who fitted him for a passy-muir valve. initially he was only able to wear the valve well supervised and became too short of breath to tolerate it all of the time. however, within a few days the patient was tolerating the valve around the clock and was phonating adequately well. he was continued on a trach collar and during the remainder of his acute hospitalization no plans were made to downsize or decannulated his trach. this has been a source of significant frustration in the patient as he believes that he is unable to lay fully recumbent at night due to his trach. it is our belief, however, though that he is unable to lay flat at night due to his diaphragmatic paralysis with resultant orthopnea. as the patient was cared for on the floor he did have some secretions coming from his trach. a sputum sample was sent that grew gram negative rods, this prompted us to start him on levaquin which he had been on for some time in the intensive care unit. the culture ultimately grew sternotrophomonas which was sensitive to bactrim and bactrim double strength was added. the patient's trach site requires cleaning with peroxide almost every shift and we anticipate this purulence to improve after the patient is either downsized or decannulated. gastrointestinal - the patient had an oral feeding tube that was placed while he was in the intensive care unit. he received full strength tube feeds through this for several days. eventually when the patient had his tracheostomy placed a percutaneous gastrostomy was also inserted. tube feeds were started soon after at trophic levels and attempts were made to increase to goal. it is believed that the patient has undiagnosed diabetic gastroparesis and we had significant difficulty with gastric residuals. we were never able to get above 40 cc/hr of continuous tube feed without the patient either vomiting or feeling extremely uncomfortable. it should be noted, however, at this time that he had gone several days without a bowel movement. his bowel regimen was changed to include some motility agents and more stool softeners. during this time on the floor he did require a disimpaction in which several large stool balls, the size of eggs, were extracted. after this time he had several large stools and significantly better. he did have a swallowing evaluation done that included video swallow. at that time they cleared him to take in soft solids and nectar thickened liquids. his food intake was variable and the decision was made to supplement him through his percutaneous endoscopic gastrostomy with tube feeds. by the time of his discharge he was tolerating bolus tube feeds of 360 cc of promod with fiber through his percutaneous endoscopic gastrostomy tube four times a day. this meets approximately 75% of his estimated nutritional requirement. he did have a calorie count around , which showed that he is taking in approximately 22% of his estimated caloric feed. we suspect that as his trach is removed and his swallowing status is liberalized he will be able to take in more. we have him on reglan and erythromycin through his percutaneous endoscopic gastrostomy to aid with gastric emptying. in addition he is on colace and lactulose to prevent him from becoming constipated. one thing that is necessary to point out to the rehabilitation team assuming his care is the current status of his percutaneous endoscopic gastrostomy. it appears that when his percutaneous endoscopic gastrostomy was inserted, perhaps the anchor was to tight. there does appear to be some ischemic necrosis at the level of the skin. his anchor was very gently loosened by approximately 1 cm so it is flush against the skin but does not press into it. we do not believe that we lessened it excessively and we do not have any suspicion that he is leaking any fluid into his peritoneal cavity from a percutaneous endoscopic gastrostomy that is inadequately anchored. he does have some purulence of the site that is being cleaned with peroxide q. shift and covered gently with a drain sponge. infectious disease - the patient while he was in the intensive care unit had his right internal jugular line site swabbed that grew multiple organisms including alpha streptococcus and two types of beta streptococcus. therefore he is coagulase negative staphylococcus and hemophilus species. for this reason he was started on levaquin with improvement of his symptoms. in addition on the hospital floor the patient had a positive sputum culture for his sternotrophomonas. while we were awaiting its speciation he was restarted on his levaquin for treatment of his gram negative rod. once it was found to be sternotrophomonas, bactrim was added to his regimen. we estimated that he will need another seven to ten days of outpatient treatment with this antibiotics. during all of this time his white count continued to trend downward. his white count was as high as 17,000 on , it normalized over the course of several days and on the day prior to his transfer his white blood cell count was 8.5. hematology - the patient was transfused with only a total of 3 units of packed red blood cells during his hospitalization. two of these transfusions were at the recommendation of the congestive heart failure service for a hematocrit of 26 and a desire to mobilize some of his interstitial fluid. his hematocrit prior to transfer was 29.1. in addition the patient was anticoagulated for many, many days on a heparin drip. when he arrived on the floor his drip was discontinued as he was becoming therapeutic on his coumadin. we believed his coumadin regimen was going to be stable at either 2 or 3 mg per day or some combination thereof. however, as medications were started and discontinued, his coumadin level became somewhat variable in the last week and his inr has been as high as 2.9 and as low as 1.2. on the day prior to transfer he did receive 5 mg of coumadin instead of 2 or 3. in addition the decision was made to start him on lovenox. while he is inadequately anticoagulated, he is receiving 40 mg of subcutaneously b.i.d., primarily for deep vein thrombosis prophylaxis, but also following his numerous episodes of atrial fibrillation while he was in the intensive care unit. neuro/psyche - the patient after being extubated complained of left upper extremity weakness. after his complaints persisted and 4/5 strength in his left upper extremity was noticed a neurology consult was obtained. they noted that he had upper motor neuron deficit symptoms in his left upper extremity and felt that this may be due to a cortical or subcortical infarct. they hypothesized that he may either have thrown a clot during one of his episodes of atrial fibrillation or that he had a low flow state at some point that left him with a very small infarct. a computerized tomography scan was obtained of his head that demonstrated only a sylvian fissure cyst and was thus interpreted as otherwise normal. there was no area of hemorrhage or ischemic infarct visualized. the neurology consult team believed that his left upper extremity weakness is a phenomenon that would respond very well to occupational therapy. in addition he was followed by one of our psychiatrists here for his complaints of sleep and for his agitated and sometimes difficult behavior. the patient was started on remeron 15 mg p.o. q.h.s. to aid with his sleep. in addition he had some intravenous haldol that was used sparingly during times of agitation. he did have some episodes of yelling and shouting and interacting in a noncooperative manner with the staff. he was never violent, physically agitated or in need of restraints. endocrine - the patient is known to be both diabetic and hypothyroid. he was followed by an endocrinologist here in the hospital who oversaw his synthroid administration. while the patient was taking p.o. his synthroid dose was 300 mcg q.d. for a period of time in the intensive care unit he had to be switched to an intravenous form and was then maintained on 100 mcg q.d. his last tsh was on and was 13 which was an improvement over 32 on . at this time we have no plans to change his current synthroid dose. in addition during his hospitalization he was maintained on insulin. his endocrinologist recommended that we simply convert his 70/30 dose at home to what he is on now. this obviously is subject to many changes when he arrives at rehabilitation and we have their recommendation as to how it should best be managed. at the time of his discharge he was on 21 units of nph and 9 units of regular in the morning in addition to 14 units of nph and 6 units of regular in the evening. he is also covered with a sliding scale. this appears to have kept his blood sugars in the 100 to 180 range. this hospitalization was dictated on in anticipation of his transfer to rehabilitation the following day. transfer medications: 1. levaquin 500 mg p.o. q.d. times seven days 2. bactrim ds 1 b.i.d. times seven days 3. synthroid 300 mcg q.d. 4. colace 100 mg b.i.d. 5. potassium chloride 20 meq b.i.d. 6. digoxin 0.125 mg q.d. 7. reglan 10 mg q.i.d. 8. erythromycin 250 mg q.i.d. 9. lactulose 30 cc b.i.d. 10. enteric coated aspirin 325 mg q.d. 11. zantac 150 mg b.i.d. 12. lopressor 25 mg b.i.d., hold for heartrate less than 55, systolic blood pressure less than 100 13. amiodarone 400 mg q.d. 14. remeron 15 mg q.h.s. 15. morphine sulfate 1 to 5 mg subcutaneously/intramuscularly q. 3-4 hours prn 16. serax 15 to 30 mg q.h.s. prn 17. nph and regular 21 nph/9 regular in the am, 14 nph/6 regular in the pm 18. zestril 2.5 mg q.d., hold for systolic blood pressure less than 90 19. bumex 3 mg b.i.d. 20. coumadin 3 mg q.h.s., note this may require a significant adjustment 21. lovenox 40 mg subcutaneously b.i.d., while not therapeutic on coumadin discharge disposition: to acute rehabilitation, likely . discharge diagnosis: 1. coronary artery disease, status post coronary artery bypass graft times four 2. acute st elevation, myocardial infarction 3. atrial flutter/rapid atrial fibrillation 4. cardiogenic shock 5. acute left hemothorax 6. respiratory failure with multiple failed extubations, now status post tracheostomy 7. paralyzed left hemidiaphragm 8. need for enteral access, status post percutaneous gastrostomy tube 9. congestive heart failure 10. suspected cortical or subcortical stroke with left upper extremity upper motor neuron signs 11. hypercholesterolemia 12. insulin dependent diabetes mellitus 13. hypothyroidism , m.d. dictated by: medquist36 d: 19:36 t: 21:24 job#: procedure: insertion of intercostal catheter for drainage (aorto)coronary bypass of three coronary arteries single internal mammary-coronary artery bypass combined right and left heart cardiac catheterization other electric countershock of heart percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy implant of pulsation balloon exploratory thoracotomy diagnoses: subendocardial infarction, initial episode of care congestive heart failure, unspecified atrial fibrillation diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled cardiogenic shock infection and inflammatory reaction due to other vascular device, implant, and graft disorders of diaphragm iatrogenic cerebrovascular infarction or hemorrhage other postablative hypothyroidism 

Answer: The patient is high likely exposed to