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: patient recorded as having no known allergies to drugs attending: chief complaint: colovesicular fistula major surgical or invasive procedure: nasal endoscopy, nasopharyngoscopy endoscopically, and laryngoscopy. history of present illness: the patient is a 62 year old male with a cardiac history significant for four vessel cabg in at (now with patent lima-lad and svg-om1 and occluded svg-om2 and svg-rpda), poba of lcx in , and des to proximal lcx in 5/. he had a ct on showing a perforated sigmoid diverticular abscess with involvement of the bladder wall. he had a cystoscopy on , which showed a likely colovesicular fistular at the bladder dome, as well as a small lesion at the trigone, which was biopsied and found to be nonmalignant, reactive urithelium. he was admitted to on for urinary retention, abdominal pain, and fever. a catheter was placed, finding 1.5 l of retained urine. he was febrile to 101.7 f at that time, and his antibiotic coverage was broadened from a planned week long course of cipro to levofloxacin and flagyl. . his hospital course was complicated by continued fever, perisepsis, and a subsequent nstemi due to demand ischemia. on , he spiked a fever up to 104 f and became tachycardic to at least changes. the following morning troponins were 0.63 and ck was 424, peaking at 1.57 on . he never had any overt chest pain. . he also developed without significant oliguria, likely due to ischemic atn. his cr was 1.1 on , steadily increasing over the next few days to a peak cr of 4.3 on . his antibiotics were changed to zosyn in the setting of his worsening condition on , and his clinical status slowly improved. he was transferred to on for further cardiac workup and possible fistula repair surgery. . on arrival to the floor he was clear, coherent, and chest pain free with vitals of t 98.5, bp 187/97, hr 74, rr 20, and spo2 99% on 4l nc. blood pressures were reportedly as high as 200/100 at the osh, and he was reportedly on an esmolol drip for a brief period, but later titrated to metoprolol 200 mg po bid. per report, but not documented, the patient was intermittently too nauseous to tolerate good po intake. he had an ng tube in place and had been started on tpn for nutrition at the osh. . on review of systems, he denied any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denied any exertional buttock or calf pain. he did report diarrhea and foul cloudy brown urine. . cardiac review of systems was notable for the absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . past medical history: past medical history: # cad: mi in and -- four vessel cabg at in -- poba of lcx on -- des to lcx on # hypertension # hyperlipidemia # dm-type ii (borderline) # sleep apnea -- on cpap # arthritis -- mostly fingers # hernia repair as an infant # arthroscopy of the left knee cardiac risk factors: +diabetes, +dyslipidemia, +hypertension cardiac history: # cabg: four vessel in at (patent lima-lad and svg-om1, subsequently occluded svg-om2 and svg-rpda) # percutaneous coronary interventions: -- in , he underwent pci (poba only due to difficulty delivering stent) of the origin lcx with 30-40% residual stenosis and stable mild dissection performed after recurrent angina and an abnormal nuclear stress. -- in , he had a repeat cath for progressive repeated angina. he underwent des to ostial proximal lcx after showing 80-90% disease. he also had diffuse (60-70%) proximal lcx disease and reported 3vd. . . 2d-echocardiogram at osh: ef 50-55%, lvh, septal hypokinesis, trace mr. . osh imaging: abdominal ct - colovesicular fistula likely secondary to sigmoid divericuli. . ett (): he underwent a nuclear stress test on where he was able to exercise 6 minutes 35 seconds to a maximum heart rate of 113 bpm. nuclear imaging revealed an inferior wall mi, mild ischemia in the in the mid to basal septum, inferior and septal hypokinesis, lv systolic dysfunction and an ef of 45%. . echocardiogram (): echocardiogram from revealed a slightly enlarged la and aortic root, normal systolic function of both ventricles, and lvef of 75%. . cardiac cath (): ptca comments: initial angiography showed recurrent severe (80-90%) ostial lcx stenosis followed by diffuse (60-70%) proximal lcx disease. we planned to treat this with ptca and stenting. bivalirudin was commenced prophylactically. the patient also receieved asa and plavix (chronically on 75 mg daily and was reloaded post procedure with additional 600 mg). a 4.0 xb guide provided excellent support and a choice pt extra support wire crossed the lesion without difficulty. we performed serial inflations staring with 1.5x15 maverick balloon (at 10-12 atm), 2.5x15 mm voyager at 8-12 atm) and 3.0x15 mm voyager (at 7-14 atm). we then delivered a 3.0x15 mm endeavor des at 18 atm, post-dilated with 3.0x15 mm quantum maverick at 20 atm and 3.5x8 mm quantum maverick at 10 atm. final angiography showed 0% residual stenosis with timi 3 flow and no dissection or distal emboli. the patient left the cath lab in stable condition and free from angina. comments: 1- successful ptca and stenting of the ostial-proximal lcx with a 3.0x15 mm endeavor des, post-dilated to 3.5. final angiography showed 0% residual stenosis with timi 3 flow and no dissection or distal emboli. final diagnosis: 1. three vessel coronary artery disease. 2. successful ptca and stening of the ostial-proximal lcx with an endeavor drug-elluting stent. . social history: he is married with two grown children. he works as a general salesman for an elevator company. smoking: quit ~20 years ago, previously smoked 2 ppd for 15 years alcohol: occasional, social drugs: none family history: father died of a mi at age 32. otherwise noncontributory. physical exam: physical exam on admission: vs: t 98.5, bp 187/97, hr 74, rr 20, spo2 94% on 4l general: middle aged male in nad. oriented x3. mood, affect appropriate. heent: ng tube in place, ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp flat cardiac: pmi located in 5th intercostal space, midclavicular line. rrr with normal s1, s2. loud sem heard throughout precordium. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. mild crackles at the bases bilaterally. abdomen: soft, nt, nd. no hsm or tenderness. abdominal aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. some bruising noted around picc site. pulses: ...right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ ...left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ . . physical exam on transfer: vs: t 97.7(96.3-98.0), bp 142/86(130-153/83-94), hr 78(64-78) ....rr 18(16-18), spo2 97(94-98) on ra, uses cpap for sleep apnea ....wt 100.2 kg today, 101.6 kg yesterday, 107.3 kg at admission gen: middle aged male in nad. alert and oriented x3. mood and affect improved from admission. resting in bed. heent: ncat. perrl, eomi, anicteric sclera. mmm, op clear. neck: supple. jvp not elevated. no cervical lymphadenopathy. cv: rrr. normal s1, s2. no m/r/g appreciated. chest: respiration unlabored, no accessory muscle use. lungs ctab. good air movement. no wheezes, rhonchi, or rales. abd: active bowel sounds. soft, obese, nt, nd. no hsm detected. foley with yellow/brown urine and some sediment. ext: wwp, no cyanosis or clubbing. no le edema. digital cap refill <2 sec. distal pulses radial 2+, dp 2+, pt 2+. skin: picc line entry site with ecchymosis, no signs of infection. healing echymosis on right arm. no other rashes, ecchymoses, or lesions noted. . . pertinent results: hematology: blood wbc-7.3 rbc-2.77* hgb-8.9* hct-25.4* mcv-92 mch-32.0 mchc-34.9 rdw-14.5 plt ct-222# blood wbc-6.6 rbc-3.40* hgb-10.6* hct-30.7* mcv-90 mch-31.1 mchc-34.6 rdw-15.2 plt ct-180 . electrolytes: urean-42 creat-3.2* urean-29 creat-3.1* urean-34 creat-4.3* urean-27 creat-2.7* urean-27 creat-2.6* . cardiac enzymes: 12:37am blood ck-mb-2 ctropnt-0.60* 05:16am blood ck(cpk)-27* 05:16am blood ck-mb-1 ctropnt-0.45* . . radiology report chest (portable ap) study date of 10:08 pm indication: confirmation of picc line placement. comparison: no comparison available at the time of dictation. findings: status post sternotomy and cabg. the picc line is inserted over the left upper extremity, the tip projects over the cavoatrial junction. normal course of a nasogastric tube. low lung volumes, moderate cardiomegaly without signs of pulmonary edema. no pleural effusion. no focal parenchymal opacity suggesting pneumonia. . tte (complete) done at 4:20:48 pm left ventricle - ejection fraction: 45% to 50% conclusions: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional function is difficult to assess but there appears to be inferior and inferoseptal hypokinesis. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality. regional function difficult to assess; probable inferior and inferoseptal hypokinesis with mildly depressed left ventricular function. mild right ventricular dilation with mild hypokinesis. . radiology report renal u.s. study date of 2:56 pm history: colovesicular fistula with acute kidney failure with recent sepsis, evaluate for abscess or obstruction. renal ultrasound: the right kidney measures 11.4 cm. the left kidney easures 11.9 cm. there is no evidence of hydronephrosis, solid renal masses or renal calculi. the right kidney contains a simple cyst in the lower pole measuring 2.7 x 3.1 x 3.7 cm. there is no evidence of perinephric fluid collection. impression: no evidence of hydronephrosis or solid renal masses. simple cyst in the right kidney. . ct abd : progression of segmental diverticulitis of the sigmoid colon with regional focal contained perforation. no free air in the upper abdomen or drainable collections. exophytic sigmoid diverticulum is increasingly decompressed with an air-fluid level and communication with the urinary bladder is less well visualized given urinary bladder decompression with foley catheter. stable appearance of the kidneys. inadequately evaluated hypoattenuating lesions, most likely cystic. cholelithiasis unchanged. . video swallow : no gross aspiration or penetration seen. no evidence of obstruction or extravasation. brief hospital course: the patient is a 62 year old male with a cardiac history significant for four vessel cabg in at (now with patent lima-lad and svg-om1 and occluded svg-om2 and svg-rpda), poba of lcx in , and des to proximal lcx in 5/. he had a ct on showing a perforated sigmoid diverticular abscess with involvement of the bladder wall. he had a cystoscopy on , which showed a likely colovesicular fistular at the bladder dome, as well as a small lesion at the trigone, which was biopsied and found to be nonmalignant, reactive urithelium. he was admitted to on for urinary retention, abdominal pain, and fever. his hospital course was complicated by continued fever, sepsis, and a subsequent nstemi due to demand ischemia with a troponin of 1.57 at its peak. he also developed , likely due to ischemic atn, with a peak cr 4.3 on . he was treated with cipro followed by levo/flagyl followed by zosyn, and his clinical status improved. he was transferred to for further cardiac workup and fistula repair surgery. he received cardiac and renal clearance for his surgery, which is planned for . . # perisepsis/colovesicular fistula: patient has a known nidus of infection through his fistula. there is communication of stool and gas into the bladder, though reduced since admission. patient was febrile as high as 104f with tachycardia at osh, though he has been afebrile on zosyn since the 14th. the patient will need the fistula repaired, hopefully in the near future, as the patient will continue to have interrmittent utis and associated complications until the issue is addressed. ct images and reports from the osh were obtained and uploaded. blood and urine cultures showed no growth. his foley catheter continues to drain somewhat feculent urine, though much improved from the time of admission. he was continued on zosyn 2.25 g iv q6h during his hospital stay. urology and surgery were consulted and plan for surgery on . . # enzyme leak/nstemi: this patient has an excellent story and setting for demand ischemia, given his underlying known cad, high heart rate, and fevers. echo on showed probable inferior and inferoseptal hypokinesis with an lvef of 45-50%. given his active renal failure and overall more pressing issues, aggressive medical optimization outweighed cardiac cath. he was increased to full dose aspirin and his other cardiac medications were continued except for his ace inhibitor, which was held due to his reduced renal function. heparin was not appropriate as the event was greater than 48 hours ago and was most likely demans rather than thrombotic in origin. he does need aggressive bp and heart rate control to reduce strain on his heart. . # htn: he had elevated blood pressures up to sbp 200 at osh. in the setting of recent demand ischemia, he needed agressive but cautious bp control. he should not receive diuretics or ace inhibitors given his . he was started on a nitro drip on admission, but maintained sbp 126-171 overnight on without the drip. the nitro drip was discontinued on and he was started on a low dose nitro patch. he continued to have elevated bp, so hydralazine 25 mg po q6h was added with some improvement. his blood pressures stabilized by on a combination of metoprolol 200 mg po bid, amlodipine 10 mg po daily, hydralazine 25 mg po q6h, and nitro patch 0.2 mg/hr. on , his nitro patch was increased to 0.4 mg/hr due to his bp rising somewhat over the prior few days. . # : the patient's cr was 3.2 on admission, significantly improved from a maximum of 4.3 at osh, but still increased from a baseline cr of 1.0 on in our system. osh records show a cr 1.0-1.1 on the days immediately prior to his nstemi on . his is most likely due to ischemic atn in the setting of perisepsis, with a possible component of ain from multiple antibiotics, though this is less likely. urine and serum lytes showed una 75, ucr 63, sna 146, scr 3.1 giving fena 2.53%, which is consistent with atn. his urine was positive for rare eosinophils. renal us on did not show any evidence of obstruction or abscess. repeat urine lytes on showed a fena of 3.04% and feurea of 69.72% with urine osmolality 333, urea 390, cr 51, na 72, k 15, and cl 63. these results remained consistent with atn. his cr remained fairly stable in the range 3.0-3.3 since admission. renal consult agreed with the diagnosis of atn and was following. . # anemia: his hct was quite variable early after admission, possibly representing at least one erroneous value. his hct on was recorded as 33.1, close to a previous value of 32.1 on . anemia labs including iron panel, b12, folate, retic count, and repeat hct were sent to work up his anemia. the anemia workup was consistent with anemia of chronic inflammation. gi bleeding was a concern given his history of diverticulosis and recent guaiac positive stools. he also had blood on urinalysis, possibly coming from his colovesicular fistula. his hemodynamics did remain stable during his admission. after starting iv fluids on , his hct dropped to 28.6, likely due to hemodilution. his hct stayed below 30 on subsequent labs, and he was given 1 unit of blood on , with a smaller hct increase than expected. his hct then stabilized at just above 30. it was recommended to consider transfusing again for hct <30. an active type and screen was kept on file during his stay. . # diarrhea: there was obvious concern for c.diff given the multiple broad spectrum antibiotics he had taken recently. stool c.diff toxin assay was sent and was negative. his agressive bowel regimen may have been playing a role and was reduced. urine leakage into the colon from his fistula was another possible contributing factor. his diarrhea improved after admission, but worsened again after resuming po intake of clears and full liquids. it improved after restarting solid food. . # bladder spasm: he did not complain of bladder spasm since admission and did not need the oxybutinin. it was kept as an active order, however, as oxybutinin 5 mg po q8h prn. . # sleep apnea: he was continued on cpap while in hospital. . # diabetes: his diabetes was only borderline prior to admission. his oral diabetes medication were held while in the hospital and he was written for an iss. however, he required only minimal insulin during his stay since his glucose levels usually remained within a normal range. . # fen/lytes: on admission, the patient was npo with an ng tube and was receiving tpn for bowel rest in setting of his fistula. surgery recommended advancing diet and discontinuing tpn on . his ng tube was pulled and he was started on clears, which was subsequently advanced to full liquids, and then a cardiac/diabetic diet. he tolerated this diet well. he had some loose stools after starting a liquid diet, but this improved after starting a regular diet. due to concern for gi losses, he was started on maintenance fluids, ns at 75 ml/hr. . pt was transferred taken to the or on with intention of performing a sigmoid colectomy and repair colovesicular fistula. during preoperative preparation there was concern that the ngt placement attempt had created a false passage. ent was consulted and the patient was kept intubated and transferred to the icu without surgery being performed. he was extubated and started on clears two days later, and transferred to the floor on . . pt's post-extubation course was largely unremarkable with excellent pain control, nutritional support, continued dvt and pud prophylaxis, and improving physical exam and clinical picture. one outstanding issue was blood pressure control with transient pressures as high as 170/100 which continued to be refractory to home dose metoprolol and amlodipine. hydralizine was added with resulting pressures in the 130/80 range. medications on admission: home medications: ciprofloxacin 500mg metoprolol 200mg plavix 75mg aspirin 325mg daily crestor 40mg daily prinivil 10mg daily . medications on transfer from osh: aspirin 81 mg po daily plavix 75 mg daily heparin 5000 units sc tid metoprolol 200 mg po bid crestor 40 mg po daily nitro paste nitro sl zosyn 2.25 g po q8h riss miralax zantac 150 mg zofran 4 mg q8h prn compazine phenergan reglan 5 mg q6h prn vomiting senna belladonna/opium suppository tylenol 1000 mg q6h prn pain oxybutinin 5 mg prn for bladder spasm hyoscyamine prn spasms ambien 5 mg ativan 0.5 mg prn anxiety morphine 2 mg q2h prn pain discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. crestor 40 mg tablet sig: one (1) tablet po once a day. 4. oxybutynin chloride 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for bladder spasm. disp:*90 tablet(s)* refills:*2* 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*30 tablet(s)* refills:*0* 6. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for headache. 8. metoprolol tartrate 100 mg tablet sig: two (2) tablet po twice a day. 9. nitroglycerin 0.4 mg/hr patch 24 hr sig: one (1) patch 24 hr transdermal q24h (every 24 hours). disp:*30 patch 24 hr(s)* refills:*2* 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 11. ciprofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*90 tablet(s)* refills:*2* 12. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): thru . disp:*21 tablet(s)* refills:*0* 13. hydralazine 25 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: colovesicular fistula acute tubular necrosis diverticulitis hypertension contusion nasopharynx and oropharynx. secondary diagnoses: non st elevation myocardial infarction coronary artery disease diabetes mellitus type ii hypertension hyperlipidemia diverticulosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital to be evaluated for possible repair of your colovesicular fistula, an abnormal connection which developed between your colon and bladder. prior to your admission here, you developed a serious infection which put strain on your heart and caused a type of heart attack called a non-st elevation myocardial infarction (nstemi). based on your medical records and evaluation in the hospital, it was determined that a cardiac catheterization would not be helpful, and that from a cardiology perspective you would be safe for surgery. your recent illness also put strain on your kidneys, and caused a type of damage called acute tubular necrosis (atn). your kidney function is improving, but is not yet back to normal. some of your medications were stopped because they should not be used unless the kidneys are functioning properly. you also had some kidney dysfunction after you were treated with meropenum, an antibiotic used to treat diverticulitis. following discontinuation your kidney function is back at an elevated baseline. your blood pressure was significantly elevated when you were admitted to the hospital, and several changes were made to your bp medication regimen in order to bring it back down to a normal level. these medication changes are also listed below. general surgery and urology were consulted about repairing the colovesicular fistula. the surgery was scheduled for thursday but due to issues in the operating room inserting a nasogastric tube the surgery was cancelled and the ent service performed an endoscopic examination to assess your anatomy for any abnormalities or injuries during the attempted nasogastric tube placement. other than swelling in the area, no abnormalities were found. you developed acute diverticulitis on and it has taken a few days for your abdominal pain to resolve. you can now be on a low residue diet and you will stay on suppressive antibiotic therapy until your elective operation which will be 3-5 months down the road as long as you remain free of any abdominal pain. please stop taking the following medications: stop: prinivil 10 mg daily please continue taking the rest of your medications as prescribed on your discharge medication list. followup instructions: call the clinic at for a follow up appointment in weeks. call your cardiologist for an appointment next week for a blood pressure check and medication adjustments call your urologist at for a follow up appointment in 1 month md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances arterial catheterization laryngoscopy and other tracheoscopy pharyngoscopy diagnoses: anemia of other chronic disease obstructive sleep apnea (adult)(pediatric) subendocardial infarction, initial episode of care acute kidney failure with lesion of tubular necrosis unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status hematoma complicating a procedure other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure old myocardial infarction diarrhea nonspecific abnormal findings in stool contents surgical or other procedure not carried out because of contraindication diverticulosis of colon (without mention of hemorrhage) other urinary incontinence diverticulitis of colon (without mention of hemorrhage) edema of pharynx or nasopharynx intestinovesical fistula arthropathy, unspecified, hand 

Answer: The patient is high likely exposed to