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: no known allergies / adverse drug reactions attending: chief complaint: transfer for heart block major surgical or invasive procedure: none history of present illness: 68 yo male history of htn, dm, prior imi w systolic chf (ef 40%), recent gi bleed of uncertain etiology () who initially presented to with reported indigestion, fatigue and doe that started two days prior. he first noticed indigestion incl passing gas and burping, followed by the acute onset of doe with heavy breathing. his doe was profound upon raking leaves, and resolved with rest. he noted some chest tightness that was worse with deep breathing but denies a positional component. he also reports fatigue for the past few weeks. . on review of history, he reports spending a lot of time doing yard-work, but denies any camping/fishing/hunting. he reports that he has been noncompliant with his diet recently, but denies any excess salt intake. he has two pets who he often reports finding ticks on. denies any rashes, arthralgias, flu-like illnesses. on review of systems, he reports occaisional palpitations at night, and a 30lb weight loss while he was hospitalized in . in addition, he reports nocturia, loose stool, and numbness in his feet. he has chronic arthritis and stiffness in his hands. he denies chest pain, orthopnea, and pnd. he denies fever, chills, nightsweats. he denies uri, cough, or recent cold. as these symptoms were consistent with his prior episode of anemia gi bleed, he presented to osh, where his exam was reported as significant for systolic blood pressures in the 130s, engorged tick on his neck (which was removed), guaiac positive stools. labs were significant for wbc 19 (n89%), hct 29.2 (his baseline), cr 3.3, k 6.4, tropi 6.18. at , ekg demonstrated complete heart block with junctional escape in the 40s. patient was admitted for further workup. inpatient stay was significant for rising tropi to 40, with continued doe and absence of cp. patient was started on iv heparin and asa 325mg for concern for acs, and ctx given concern for possible disseminated lyme. tte reported unchanged inferolateral akinesis and ef 40%. patient was transferred to for further management. . currently he is comfortable with the exception of some mild indigestion. past medical history: 1. cardiac risk factors: + diabetes, + dyslipidemia, + hypertension 2. cardiac history: - cad with reported prior imi, no prior cath - schf (ef reported at 40%) 3. other past medical history: - dm complicated by neuropathy, ckd (a1c 6.3% ) - htn - hl - ckd (baseline cr 2.0) - chronic anemia (uncertain etiology, baseline high 30s) - chronic leukocytosis () - chronic gi bleed of uncertain etiology - barrett's esophagus - prior sbo adhesions, s/p loa social history: lives in with his wife who is bedbound from ms. is a full time caretaker with his one son that lives at home. retired. former 70 pack year smoker, quit 20 years ago. former beer drinker. denies illicits. family history: mother died of . father died of cancer. grandfather died after 3mi's and dm. physical exam: admission exam: vs: 98.3, 51, 144/63, 17, 99% on 2l nc general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. mmm. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 5 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: +bs, soft, nd, mildly tender along epigastrium. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, rashes, ulcers, scars, or xanthomas. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ . discharge exam: tm/tc:99.2/98.2 hr:51-56 bp:144-158/71-74 rr:20 02 sat: 97% ra general: 68 yo m in no acute distress, sitting in bed heent: mucous membs moist, no jvd chest: ctabl no wheezes, no rales, no rhonchi cv: s1 s2 normal in quality and intensity rrr, 2/6 systolic murmur at llsb. abd: soft, non-tender, non-distended, bs normoactive. ext: wwp, no edema. dps, pts 2+. neuro: cns ii-xii intact. 5/5 strength in u/l extremities. gait wnl. skin: no rash psych: a/o pertinent results: admission results: 02:40pm blood wbc-19.9* rbc-3.79* hgb-9.5* hct-29.5* mcv-78* mch-25.1* mchc-32.3 rdw-15.3 plt ct-244 02:40pm blood neuts-87.0* lymphs-8.0* monos-4.9 eos-0.1 baso-0 02:40pm blood pt-14.8* inr(pt)-1.3* 02:40pm blood glucose-122* urean-44* creat-2.8* na-140 k-4.1 cl-105 hco3-20* angap-19 02:40pm blood calcium-8.6 phos-4.9* mg-2.0 . relevant intermediate labs: 06:50am blood ret aut-2.1 05:30pm blood parst s-negative 02:40pm blood ck-mb-56* mb indx-6.2* ctropnt-2.85* 05:39am blood ck-mb-25* mb indx-4.4 ctropnt-2.67* 06:50am blood caltibc-255* ferritn-64 trf-196* . ecgs: 1. : sinus rhythm with a-v dissociation. left atrial abnormality. lateral st segment abnormalities and st segment elevation in leads iii and avf. these findings are consistent with active inferolateral ischemic process. rule out myocardial infarction. followup and clinical correlation are suggested. no previous tracing available for comparison. 2. : sinus rhythm with a-v dissociation as previously recorded on . there is further evolution of acute inferolateral ischemia and qt interval prolongation. rule out myocardial infarction. followup and clinical correlation are suggested. . tte (): the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral segments. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. lvef 45%. impression: normal left ventricular cavity size and wall thickness with mildly depressed regional left ventricular systolic dysfunction, as described above. mild mitral and tricuspid regurgitation. severe pulmonary artery systolic hypertension. . cxr (): the patient has received a right-sided picc line. the course of the line is unremarkable, the tip of the line projects over the right atrium, and the line could be pulled back by approximately 3 cm. there is no evidence of complications, notably no pneumothorax. the size of the cardiac silhouette is at the upper range of normal. moderate tortuosity of the thoracic aorta. no pleural effusions. normal hilar and mediastinal contours. . discharge labs: 06:00am blood wbc-11.4* rbc-3.49* hgb-8.8* hct-27.2* mcv-78* mch-25.2* mchc-32.3 rdw-15.1 plt ct-213 06:00am blood glucose-136* urean-48* creat-3.1* na-140 k-4.1 cl-108 hco3-20* angap-16 06:00am blood calcium-8.1* phos-3.4 mg-2.1 brief hospital course: 68 yo male with htn, hl, cad complicated by inferior mi, iddm, ckd, chf (ef 40%) and recent gi bleed who presented to an outside hospital with several days shortness of breath, found to have new heart block in the setting of rising cardiac enzymes with st changes on ekg. . #. high degree av block: patient presented to an osh with new-onset high-grade av block with a narrow complex junctional escape rhythm. given his history of recent tick exposure there was concern for lyme disease complicated by heart block and patient was started on iv ceftriaxone. at the osh, lyme pcr and babesia and ehrlichia dna were negative. upon arrival to , the id consult team was consulted who recommended continuing ceftriaxone. a repeat lyme serology as well as babesia directed smear were obtained at . lyme serology was pending at discharge and the babesia smear was negative. there was also concern initially for an ischemic etiology of his heart block given his ekg changes and elevated biomarkers. a tte was performed and did not show any regional motion abnormalities that were concerning for a new infarction. the tte was also performed out of concern for possible endocarditis and did not show evidence of vegetations and his blood cultures were considered not helpful as he had been treated with ceftriaxone prior to transfer. there was also concern for possible amyloidosis so spep and upep were sent but were pending at discharge. he remained hemodynamically stable throughout his hospitalization and his heart block improved throughout his stay. his metoprolol was held throughout admission. he was ultimately discharged home to continue a total of 3 weeks of iv ceftriaxone for empiric treatment of lyme disease. patient will follow-up with dr. in atrius cardiololgy electrophysiology following discharge as well as having holter monitoring arranged following dishcarge. . #. cad: patient with history of silent mi. echo with inferior/inferolateral hypokinesis but no new focal wall motion abnormalities on tte. his elevated biomarkers were attributed to a possible lyme myocarditis and less likely due to acs. he was continued on his home cad medications (with the exception of lisinopril and metoprolol) throughout his hospitalization. an enteric coated aspirin was also started and his hematocrit remained stable so it was felt that he was safe to continue following discharge despite his history of gi bleed. . #. chf: tte with ef of 45% during this hospitalization with history of ef of 40% from prior tte. patient remained euvolemic throughout his hospitalization. his cad medications were given as above. . #. on ckd: baseline creat 2.0 and creat remained at approximately 2.8 throughout his hospitalization. his acute change was attributed to decreased perfusion in the setting of heart block. hydrochlorothiazide and lisinopril were held throughout admission. his serum creatinine remained approximately at 2.8 with minor fluctuations that were not considered to reflect large changes in his gfr. . #. iddm: moderate bs control during hospital stay on home dose of lantus and ss humalog. his lantus was increased to 20 units at night for repeat fingersticks in the mid-200s. . #. htn: patient had moderately elevated blood pressures throughout . #. barrett's esophagus: outpatient follow up. patient was continued on omeprazole. . # chronic anemia: patient with recent gi bleed. he was continued on his omeprazole and iron. he was restarted on an enteric coated aspirin and his hematocrit remained stable throughout admission. . #. picc line placement: a picc line was placed on by the venous access team. cxr confirmed that the picc line projected over the right atrium and needed to be pulled back 3 cm. the line was pulled back 3 cm on . per the access team, no repeat film was needed to reconfirm placement. . transitional issues: 1. follow-up lyme serologies from 2. follow-up spep and upep from 3. follow-up anaplasma igm/igg from 4. consideration of adenosine mibi to evalute for reversible ischemia medications on admission: - simvastatin 40mg daily - lantus 15 units qhs - lisinopril 10mg daily - metoprolol succ 100mg daily - omeprazole 40mg - iron 325mg w meals - hctz 12.5mg daily discharge medications: 1. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush: to follow normal saline flush. disp:*40 ml(s)* refills:*0* 2. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: two (2) grams intravenous q24h (every 24 hours) for 17 doses. disp:*34 grams* refills:*0* 3. saline flush 0.9 % syringe sig: three (3) cc injection once a day as needed for flush for 40 doses. disp:*40 syringe* refills:*0* 4. simvastatin 40 mg tablet sig: one (1) tablet po once a day. 5. insulin glargine 100 unit/ml solution sig: eighteen (18) units subcutaneous at bedtime. 6. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 7. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po bid (2 times a day): please take with meals. 8. ecotrin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. outpatient lab work please have a chem 7 checked on and have the results sent to dr. at . discharge disposition: home with service facility: discharge diagnosis: primary diagnosis: high degree av block, possible lyme carditis secondary diagnosis: chronic systolic heart failure, diabetes, hypertension, hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you during your stay here at . . you were transferred to from for a slow and irregular heart rhythm. you were also found to have a tick on your neck. it is possible that your slow heart rhythm is a result of inflammation caused by this tick, but there is inconclusive evidence. we have started you on an antibiotic to treat potential lyme disease affecting the heart for three weeks total. this will be given to you via home infusions. you will also use a holter monitor at home to montior your heart rate. . it is possible that an occlusion in your artery could have contributed to your symptoms. we would like you to have a stress test as an outpatient with dr. . . your kidney function is worse than it was previously. please follow up with your pcp for repeat labs in one week to check your kidney function. . the following changes were made to your medication regimen: -start baby aspirin daily - you did not have any evidence of bleeding while on this dose, but please call your cardiologist and pcp if you notice any bleeding, lightheadedness, or shortness of breath -start ceftriaxone for three weeks total -hold lisinopril until you see your pcp and have labs checked -hold hydrochlorothiazide until you see your pcp and have labs checked -stop metoprolol given your slow heart rates -increase your lantus - make sure to continue eating meals at regular intervals to prevent low blood sugar. if you have low blood sugar, call your pcp. followup instructions: please pick up your holter monitor from at 10am on tuesday morning, . please attend the following appointments: name: , a location: - address: , , phone: appointment: thursday 10:40am name: , location: department: cardiology address: , , phone: *we are working on a follow up appointment the office will contact you at home with the appt information if you have any questions or concerns please call the office. dr. will set up a mibi stress test as an outpatient. md procedure: venous catheterization, not elsewhere classified diagnoses: coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes personal history of tobacco use chronic kidney disease, unspecified atrioventricular block, complete long-term (current) use of insulin old myocardial infarction chronic systolic heart failure barrett's esophagus diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled leukocytosis, unspecified lyme disease acute myocarditis in diseases classified elsewhere bite of nonvenomous arthropod insect bite, nonvenomous of face, neck, and scalp except eye, without mention of infection 

Answer: The patient is high likely exposed to