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: zestril / lipitor attending: chief complaint: fever, hypotension. transfer from hospital. major surgical or invasive procedure: central venous line placement (femoral) picc line insertion transesophageal echocardiogram history of present illness: 89 year-old male with cad s/p cabg, a fib on coumadin, cryptogenic cirrhosis, dm type 2, and myelodysplastic syndrome with pancytopenia, with recent history of enterococcus uti and bacteremia () at osh complicated by presumed subacute endocarditis (, tee negative at osh), recently discharged on from osh to rehabilitation center with picc in right arm with plan to complete a total of 4 weeks of amp and gent. on at nh, patient developed recurrent fever to 100.6, +sob with saturation 92% ra. he was given vancomycin 1 gm iv x1 and transferred to ed where bp 88/57. a dopamine infusion was initiated. a cxr was consistent with chf, with bnp 1090 and patient was given lasix 80 mg iv x1. he was subsequently transferred to the ed for further care, where bp initially 70/40 on 5 mcg/kg/min of dopamine. in the ed, blood cultures were sent. a bedside echo was performed and showed no pericardial effusion. on ros, +sob, + cough productive of white sputum. + chills at osh. the patient was admitted to the micu. past medical history: 1. cad s/p cabg in 2. dm type 2 on prandin 3. chronic atrial fibrillation on coumadin 4. myelodysplastic syndrome with pancytopenia (not transfusion dependent) 5. cryptogenic cirrhosis diagnosed by biopsy 6. chronic renal insufficiency with creatinine 2.0 7. hyperlipidemia 8. h/o chf, query diastolic dysfunction (normal ef) 9. enteroccus uti and bacteremia (), complicated by presumed enterococcus endocarditis (). social history: he lives in (ma) with his wife. remote ex-smoker, with 10 pack-year smoking history. he quit in , no etoh consumption. family history: non-contributory. physical exam: per admission note on . vs: 98.7, 117/85, hr 87, r 18, 96% 2l gen: nad, very pleasant heent: eomi, o/p clear neck: supple, jvp at 8cm chest: scattered rhonchi, wheezes, crackles at bases bilaterally cv: rrr, 3/6 sem that radiates to clavicle and carotid abd: soft, distended, nt, + bs ext: no edema, 2 piv neuro: a and o x 3, moves all 4 extremities pertinent results: relevant laboratory data on admission: cbc: wbc-2.8* rbc-2.61* hgb-9.7* hct-28.7* mcv-110* rdw-15.5 plt -102 (neuts-83* bands-2 lymphs-5* monos-9 eos-0 basos-1 atyps-0 metas-0) coagulation profile: pt-17.4* ptt-37.8* inr(pt)-1.9 chemistry: glucose-119* urea n-37* creat-1.8* sodium-138 potassium-3.4 chloride-100 total co2-33* anion gap-8 calcium-8.3* phosphate-3.4 magnesium-2.1 alt-34 ast-61* ck(cpk)-303* alkphos-148* amylase-128* totbili-2.1* lactate-2.2* random cortisol 17.5 cardiac enzymes: 02:10am ck-mb-4 c tropnt-0.09* 03:28pm ck-mb-6 ctropnt-0.08* 04:23am ck-mb-5 ctropnt-0.07* 06:11am ctropnt-0.06* urinalysis: 02:10am blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg urine rbc-0-2 wbc-0 bacteria-rare yeast-none epi-1 ekg: atrial fibrillation. probable old septal infarct. inferior/lateral t changes are nonspecific. repolarization changes may be partly due to rhythm. since previous tracing, no significant change. cxr: the cardiac contour is somewhat rounded, but normal in size. mediastinal contours are normal. there is slight blunting of both costophrenic angles with minor atelectatic changes seen at the lung bases. there is no focal consolidation. pulmonary vasculature appears slightly prominent, but there is no chf. the patient is post cabg with median sternotomy wires and clips seen in the mediastinum. the osseous structures are unremarkable. impression: slight blunting of the costophrenic angles. no definite chf. no pneumonia. relevant data in hospital: tee : 1. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium. 2. left ventricular wall thicknesses and cavity size are normal. left ventricular function is normal (lvef 60-65%). 3. right ventricular chamber size and free wall motion are normal. 4.there are simple atheroma in the ascending aorta, in the aortic arch, and in the descending thoracic aorta. 5.the aortic valve leaflets are severely thickened/deformed. no masses or mobile vegetations are seen on the aortic valve, however cannot exclude a sessile vegetation (the valve leaflets are severely calcified). no aortic valve abscess is seen. there is probably moderate aortic valve stenosis (recommend transthoracic echo for complete evaluation of the aortic stenosis if clinically indicated). trace aortic regurgitation is seen. 6. the mitral valve leaflets are moderately thickened. no mass or vegetation is seen on the mitral valve. moderate to severe (3+) mitral regurgitation is seen. 7.the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. 8.there is no pericardial effusion. no prior strudy available for comparison. : limited abdomen ultrasound: there is a tiny amount of fluid adjacent to the liver. there are no loculated fluid collections. brief hospital course: 89 year-old male with mmp including cad, atrial fibrillation on coumadin, and recent admission to osh with enterococcus fecalis uti and bacteremia, complicated by presumed enteroccus endocarditis (negative tee but recurrent positive blood cultures and ongoing fever), treated with ampicillin iv (1 gm iv q 6 hours) and gentamicin iv (started on ), now admitted with fever, hypotension and respiratory symptoms. his hospital course will be reviewed by problems. 1) hypotension/fever: given the hypotension in the setting of recurrent fever and recent enterococcal bacteremia, the most likely etiology was felt to be septic shock +/- cardiogenic component. a bedside echo on admission showed relatively preserved ef, no pleural effusion. it was unclear whether his fever/hypotension were related to persistent enterococcal infection or a new nosocomial infection. cxr was without pna and u/a clear. cultures sent. given concern over potential line infection, picc line was d/c'd on admission. the antibiotic regimen was changed to vancomycin iv and gentamycin iv for rx of enterococcus +/ line infection. the patient was quickly weaned off dopamine in the icu, and was transferred to the floor on . all cultures at were unremarkable. however, mr. continued to spike fever up to 102.3 on vancomycin and gentamicin. a repeat tee was performed on , which revealed normal lvef 60-65%, and no vegetation although a sessile vegetation could not be ruled out given severe calcification of aortic valve. probable moderate as, trace ar, moderate to severe mr (mild mr in ), moderate tr. an abdominal u/s was also performed, which revealed a small amount of ascites and no fluid collection. id was consulted. given his respiratory symptoms, levofloxacin 500 mg po qd was added to cover for pulmonary organisms. a nasal wash was also sent to rule out influenza, which came back positive for influenza a. in retrospect, his acute presentation was felt likely secondary to influenza. given the duration of his symptoms and clinical improvement, decision was taken not to treat. he was kept on droplet precautions in hospital (d/c'd on ). levofloxacin d/c'd on . respiratory symptoms resolved at the time of discharge. intermittent wheezing in hospital, kept on albuterol and ipratropium nebs prn. of note, sensitivities were repeated on the osh isolate and ampicillin sensitivity was confirmed, mic <=2. antibiotics were changed back to ampicillin 1 gm iv q 6 hours, and gentamicin 80 mg iv q 48 hours (dose adjusted according to levels and creatinine) on . ampicillin increased to 2 gm iv q 8 hours on after discussion with id team. plan is to complete 6 weeks of therapy with ampicillin and gentamicin (last doses on ). picc line in place. will need gentamicin levels every 4th day (goal peak=3, trough=1). hold gentamicin if creatinine >2.5. 2) chf: lasix and spironolactone were held on admission given hypotension, restarted on . cxrs in hospital revealed progressive fluid overload, and lasix dose was titrated up to maintain negative fluid balance. per patient's wife, out-patient lasix dose is 160 mg po qam and 120 mg po qpm. on lasix 80 mg po bid at discharge, with goal to titrate to even to negative fluid balance as an out-patient. weight 140lbs. low threshold to increase lasix if increasing edema on exam, or >=3lbs weight gain as creatinine tolerates. 3) cad: troponin 0.09 (peak) on admission, felt likely troponin leak in the setting of infection and renal failure. ekg without acute ischemic changes. in hospital, he was continued on metoprolol and asa. history of adverse reaction to ace. also continued on zetia for hyperlipidemia. 4) atrial fibrillation: metoprolol initially held in the setting of hypotension, restarted as bp tolerated. good rate control on 25 mg po bid. patient also continued on coumadin, with goal inr . coumadin dose decreased to 1 mg po qhs given elevated inr in hospital (out-patient dose 2mg po qhs). inr 2.0 will need close monitoring at rehab. 5) diabetes mellitus type 2: poor glycemic control in hospital. prandin was held, and he was started on glargine at night, titrated up to 9 units qhs, along with riss, with plan to manage on glargine as an out-patient. patient will need teaching at rehab center. would not restart prandin. 6) mds with pancytopenia: per patient's pcp, hct around 32-33. while in hospital, patient transfused a total of 3 units of prbcs to maintain hct >30 given known cad. platelets stable in low 100k, and wbc around of 3. 7) chronic renal insufficiency: creatinine around of 2 in hospital, slightly higher on at 2.2. gentamicin levels monitored carefully in hospital given risk of nephrotoxicity and ototoxicity. patient will need gentamicin levels q 4 days, with goal peak=3 and trough=1. plan to d/c gentamicin if creatinine >=2.5. 8) cryptogenic cirrhosis: patient continued on spironolactone and lactulose in hospital. of note, patient noted to have mild elevation of alkaline phosphatase, total bilirubin and ggt in hospital, also elevated at osh. abdominal u/s at osh negative for cbd dilatation, no gb wall thickening, no pericholecystic fluid. no acute issues in hospital. 9) prophylaxis: on coumadin, protonix (history of pud) and bowel regimen in hospital. code: dnr/dni per discussion with patient and family. medications on admission: meds on transfer from micu: coumadin 2 mg po qd lasix 80 mg iv qd spironolactone 25 mg po qd gentamicin 120 mg iv qd (d2) lacutlose 30 mg po tid vancomycin 1 g iv qd (d2) dulcolax 10 mg po/pr prn senna prn atrovent neb q 6h albuterol neb q 6h prn asa 325 mg po qd zetia 10 mg po qd colace 100 mg po bid folate 1 mg po qd mvi 1 po qd protonix 40 mg po qd celexa 10 mg po qd riss tylenol prn discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. multivitamin capsule sig: one (1) cap po daily (daily). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6hrs: prn as needed for shortness of breath or wheezing. 10. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6hrs: prn as needed for shortness of breath or wheezing. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 13. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 15. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day): titrate to 2 bm per day. 16. warfarin sodium 1 mg tablet sig: one (1) tablet po hs (at bedtime): please monitor daily inr until stable. 17. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a day): please monitor daily weight. . 18. gentamicin in normal saline 80 mg/50 ml piggyback sig: eighty (80) mg intravenous q48h (every 48 hours): please hold dose on .check daily creatinine; if stable or decreasing, then resume dose q48 hours on . please check gentamicin levels every 4th day (every 2 doses). last doses on . 19. ampicillin sodium 2 g recon soln sig: one (1) recon soln injection q8h (every 8 hours): please give 2 gm iv q8 hours. last doses on . 20. insulin glargine 100 unit/ml solution sig: nine (9) units subcutaneous at bedtime. 21. regular insulin sliding scale discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary diagnoses: influenza a probable enterococcus endocarditis coronary artery disease atrial fibrillation congestive heart failure diabetes mellitus type 2 myelodysplastic syndrome chronic renal insufficiency secondary diagnoses: cryptogenic cirrhosis hyperlipidemia discharge condition: patient discharged to rehab facility in stable condition. discharge instructions: patient will need follow-up with pcp (dr. after d/c from rehab facility. please arrange follow-up appointment prior to d/c. followup instructions: please arrange follow-up with dr. (pcp) prior to d/c from rehab. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart transfusion of packed cells infusion of vasopressor agent diagnoses: cirrhosis of liver without mention of alcohol diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia severe sepsis atrial fibrillation rheumatic heart failure (congestive) septic shock mitral valve insufficiency and aortic valve stenosis acute and subacute bacterial endocarditis streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] influenza with pneumonia 

Answer: The patient is high likely exposed to