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: coagulase-negative staph bacteremia complicated by vegetation on icd line, pericardial effusion c/b tamponade major surgical or invasive procedure: icd removal endotracheal placement and removal tracheostomy electrophysiology study history of present illness: 54 yr/o m with hx of dm, htn, ckd, chf (last ef 40-45%), mi s/p 3 stents (), afib (on warfarin and s/p ablation), with icd placed in who presented to (osh) on with sudden onset of chest pain that had started on and was accompanied by fever and chills but which had resolved by arrival at osh and that had been preceeded by 5 day history of malaise. also had a productive cough at presentation which is near home baseline. he says cough is due to sinusitis. presening wbc 12.9, hgb 7.4, plts 23. cr 1.6-1.8 with albumin 2.8 and inr 2.9 - cardiac enzymes ruled out. initially was transfused 3 units of blood for anemia. at osh pt was apparently diagnosed with an icd vegetation with multiple blood cultures growing coag neg staph ( on day 1, on day 3, on day 5 per micro tech). he was started on vancomycin on and also received 4 days of levofloxacin. he developed pericardial tamponade and had a pericardiocentesis yesterday with drainage of 500cc bloody fluid. a pericardial drain was placed and drained 200cc since placement but was removed late this am. he received a tee with etomidate sedation 1 hour prior to transfer and after proceedure was sob and placed on a 50% venti-mask. he also went into afib/flutter with rvr to the 130-140s after the tee and was given 15mg total iv metoprolol with bp at 108/70 prior to transfer. he also has a left pleural effusion which had developed during stay. immediately before transfer he received another echo to ruleout reaccumulation of pericardial fluid as he had become more tachypnic and had low bps. at time of transfer pt was on no drips, was not intubated, and was not requiring pressors. patient reports that he had been getting dyspnic with little exertion the few days prior to arrival at osh. currently walks with a cain and has low exercise tolerance. chest pain has subsided and patient does not feel he is having palpitations. past medical history: 1. cardiac risk factors: +diabetes, -dyslipidemia, +hypertension 2. cardiac history: - cabg: none - mi: past mi (?) - percutaneous coronary interventions: s/p 3 stents - pacing/icd: icd placed in - had vf arrest with inducible vt at same time as cva in (reason for icd placement) 3. other past medical history: - cva (thought to hypoxia as had vf arrest at same time) - ckd (baseline cr?) - anemia - gerd - hx mrsa in sputum () social history: lives with wife. smoked until at which time he quit. smoked 2 ppd before that for 15years. occasional etoh. denies elicit drugs. family history: one sister with htn/dm who died after clotted tracheostomy (likely pe by description). brother died at 55 with cad and htd (says brother died of an mi). father had htn and lung ca (deceased). mom had dm, mi, and had pacer placed. physical exam: admission physical exam: vs: t=103.1, bp=108/63 hr=130-160s, rr=26, o2 sat= 96% on 6l nc general: mildly uncomfortable. oriented x3. heent: ncat. sclera anicteric. perrl, eomi. poor dentention. neck: supple with no significant jvp elevation cardiac: pmi located in 5th intercostal space, midclavicular line. rr, soft s1, s2. difficult to assess for murmurs due to faint hs lungs: decreased breath sounds on left compared to right, mildly tachypnic, no crackles, trace intermittent wheezing abdomen: soft, distended to habitus, no hsm or tenderness. extremities: no c/c/e. poor foot hygeine, no stigmata of endocarditis pulses: right: radial 2+ dp 2+ pt 2+ left: radial 2+ dp 2+ pt 2+ discharge physical exam: general: awake, responsive, and conversant. fully oriented and converses appropriately, although difficult to understand at times. heent: ncat. sclera anicteric. pupils small but symmetric and react slightly, eomi appear intact. poor dentition but otherwise op clear. neck: supple without significant jvp elevation cardiac: rr, soft s1, s2. difficult to assess for murmurs due to faint hs lungs: mildly decreased bs, mostly decreased at left base. abdomen: soft, distended to habitus, no tenderness apparent. extremities: mild trace edema throughout. pertinent results: outside hospital studies: - tee (): dense structure attached to icd lead, normal lv/rv structure and fucntion, no evidence of pericardial effusion, left pleural effusion - tte (): moderate pericardial effusion with tamponade physiology, abnormal septal motion with diastolic collapse, mildly dilated - stress (): no report but osh hpi mentions reversible ischemia, apex ef 55%, hypokinetic apex -cxr pa/lat (): no acute process -chest ct (): small pericardial effusion, mediastinal lns up to 1.3cm, trace left pleural effusion with subsegmental opacities -chest ct (): bilat pleural effusions (r>l), significant increase in size of pericardial effusion with possible tamponade, no dissection, streaky inflammatory change near pancreatic head and questionable wall thickening related to gallbladder -cxr port ap (): cardiomegaly, suspected pulm venous congestion, small left pleural effusion -> repeat later in day with increased lll opacity - mrsa screen positive - ucx (): neg - bcx () 4/4 bottles + coag neg staph - bcx () 2/4 bottles + coag neg staph - bcx () 1/4 bottles + coag neg staph - bcx : anaerobic bottle coag neg staph / aerobic bottle neg drug mic clinda >2 resistant oxacillin >1 resistant pcn g >1 resistant vanco <= 0.5 susceptible cefazolin 4 resistant levoflox >4 resistant ampicillin resistant gent <=2 susceptible admission labs: 139 102 37 --------------< 78 4.6 26 1.5 ca: 9.0 mg: 1.9 p: 4.2 cardiac enzymes: ck: 110 mb: 1 trop-t: <0.01 alt: 40 ap: 137 tbili: 1.1 alb: 3.3 ast: 34 ldh: 215 wbc 17.8 / hgb 9.5 / hct 28.2 / plts 314 / mcv 78 n:82 band:1 l:11 m:6 e:0 bas:0 hypochr: 2+ anisocy: 1+ poiklo: 1+ microcy: 3+ ovalocy: 1+ pencil: occasional fragmen: occasional ellipto: occasional pt: 18.8 ptt: 33.0 inr: 1.7 ecg: afib vs aflutter (favor flutter) with intermittent conduction, rates in 150s, no significant st changes pertinent studies: tte (): suboptimal image quality. possible thrombus vs. vegetation (1 x 1.1 cm ) seen on the subcostal views which appears to be attached to the icd lead in the mid-right ventricle. tricuspid valve not well-visualized. concentric left ventricular hypertrophy with preserved global left ventricular systolic function. if clinically indicated, a transesophageal echocardiogram may better assess for icd lead mass and valvular vegetations. pleural fluid cytology : negative for carcinoma. ecg : atrial flutter with rapid and variable ventricular response. poor r wave progression. cannot rule out prior anterior myocardial infarction. non-specific st-t wave abnormalities. compared to the previous tracing of atrial flutter is new. ct chest : 1. improved aeration of the left hemithorax with residual left lower lobe atelectasis. heterogeneous loculated left pleural effusion also decreased, likely representing hemothorax versus empyema. 2. interval improvement in previously seen dense right upper lobe opacities. improvement in previous right lower lobe ground-glass opacities. 3. new dense rounded consolidation at the right base, likely new focus of infection. 4. small pericardial effusion. cxr : no large pneumothorax. brief hospital course: 54 yr/o m with significant cardiac history who presented to osh with 5 days of malaise and 1-2 days of cp, subjective fevers, and chills found to have vegetation on icd and multiple blood cultures with cons as well as pericardial effusion with tamponade s/p drainage on . #. infected icd: tee at osh, and confirmed on tte on arrival to , indicated vegetation on icd lead. difficult to know if the icd site seeded the blood or bloodstream infection then seeded icd. blood cultures grew coag-neg staph (last positive ) which has cleared with vancomycin. he had his icd removed on . his need for aicd was reassessed, given that his arrest was actually pea per records at and misclassification of vt by his aicd in the context of a misplaced atrial lead. after icd removal, he was subsequently noted to have fevers, tenderness and fluctuance over the site of his aicd pocket. us demonstrated a fluid collection consistent with a hematoma, which was drained on hd9 and did not show any overt signs of infection. he will continue vancomycin for 6 weeks after icd removal. the ep service felt that there is no clear indication that patient requires replacement of icd. cardiac mri was performed and did not show evidence of a myocardial scar that could potentiate a ventricular arrythmia. on hd11 patient was taken to the electrophysiology lab and did not have any inducible vt. his rhythms have remained stable during his hospitalization and he will follow up with cardiology as an outpatient. #. tracheal stenosis/edema: he was intubated once for his icd removal and had an uncomplicated extubation. he was then reintubated on prior to his ep study. following extubation, he was stridorous requiring reintubation. interventional pulmonology evaluated the patient via bronchoscopy and noted supraglottic edema that was not intervenable. they felt that he required tracheostomy placed temporarily until his edema resolved. he was seen by an ent specialist, dr. , and will need close follow up with him for further management. he also received 4 days of high dose steroids to decrease the edema. he will also have ip follow up for management of his trach. he did have one episode where his trach pressed up against the back of his tracheostomy site and he had respiratory distress. this was resolved with bronchoscopy and repositioning of the trach. #. coagulase negative staph bacteremia: had high grade bacteremia with blood cultures from osh positive in bottles. cultures did not clear for four days, last positive culture data from . unclear whether bacteremia started from icd or vice versa. no specific skin breaks on exam to suggest portal of entry for a common skin flora. patient was evaluated by dental who noted several dental caries that required extraction and could be potential source of infection. however, patient was unable to have panorex as he was unable to stand or sit up for x-rays. a head ct was performed and omfs determined that the patient had several dental caries requiring extraction. organism sensative to aminoglycosides/vanco only, so continued vancomycin, which was started . surveillance cultures following lead extraction were negative to date. in addition to vancomycin he also recieved a 7 day course of cefepime for empiric therapy of gram negatives and potential pneumonia. a picc line was placed on hd 8 (and replaced on due to coiling in the ij), and patient was discharged on iv vancomycin for a total of six weeks of antibiotic therapy from the date of lead extraction, ending . he will follow up with id opat note. #. pericardial effusion: patient had a pericardial effusion with tamponade physiology at osh. patient was therapeutic on coumadin and hemodynamically stable, so waited to perform pericardiocentesis for two days. drained approximately 700cc bloody fluid, and drain was removed prior to transfer as there was no reaccumulation of fluid. patient had no pulsus paradoxus on arrival to and throughout admission. repeat echo showed no evidence of reaccumulation. warfarin was initially held in setting of recent bleed but as his hct stabilized, it was restarted. #. pleural effusion: he developed a left sided layering pleural effusion during hospitalization (his as initial cxr did not show effusion). on hd4, patient had a ct guided thoracentesis of loculated pleural fluid. approximately 20cc of serosanguinous fluid was extracted. fluid was consistent with an exudative effusion. fluid culture was negative. therefore, it was felt that pleural effusion most likely was a result of pericardiocentesis performed at osh. following electrophysiology study on hd12, patient was stridorous with extubation requiring re-intubation. a repeat ct scan performed several hours later showed collapse of the left lung. cardiothoracic surgery inserted a chest tube for further drainage and a follow-up cxr showed re-inflation of the left lung. on hd15 the chest tube was clotted and tpa was inserted with good effect. his chest tube was removed on hd 20 and follow up cxr showed no evidence of reaccumulation of blood as well as stable small pneumothorax. #. atrial fibrillation with rvr: after tee at osh patient flipped into afib/aflutter with rvr to 140s and had difficulty controlling with boluses of iv metoprolol. on arrival to initial ekgs suspicious for aflutter and rates running 120-150s. as patient was febrile to 103 and declaring thirst on arrival to , possible that some of tachycardia was due to dehydration and fever. patient was on diltiazem drip at the time of transfer. dilt drip was weaned, and patient was loaded with amiodarone. oral loading continued through , and he is now dosed daily. patient was started on coumadin on hd5 and then later discontinued in anticipation of multiple procedures and then restarted . goal inr for patient will be . warfarin was restarted on hd 21 at 3mg. at the time of discharge the patients inr was 1.3. #. renal insufficiency: patient had increased creatinine at osh, with initial cr of 1.59, improving to 1.17. patient had a dye load for chest ct prior to transfer causing cr bump to 1.4. his home ace inhibitor was held briefly in the setting of . urine culture at was negative. he oscillated between 1.3 and 2.0 during the rest of his admission. his creatinine was 1.4 at the time of discharge. #. cad: history of stents placed in . patient continued on home aspirin and plavix. beta blocker and ace inhibitor held initially in setting of infection and renal insufficiency and restarted once renal function improved and blood pressures were stable. #. chf: last echocardiogram reported depressed ef of 40-45%, but at osh, echo showed normal ef. repeat tte at showed ef >55% with concentric left ventricular hypertrophy. #. anemia: on admission to osh, hct was 22 with labs consistent with iron deficiency anemia. patient was transfused a total of 3 units prbc with hematocrit remaining stable after at 27-30. at , hct was 28.2 and patient was hemodynamically stable. he was transfused 2uprbc on hd2 and hematocrit responded appropriately, increasing to 30.1. iron supplementation was held in the setting of bacteremia but restarted once patient was afebrile with a stable white blood cell count. hematocrit was stable throughout remainder of hospitalization. #. constipation: had infrequent bowel movements and needed an aggressive bowel regimen. would ensure regular bowel movements. #. transitional issues: - patient will need to follow-up at with omfs for dental extractions. - id opat follow up for vancomycin administration for 6 week total course - follow up of pending cultures (pleural fluid cultures pending) - ip, cardiology, omfs and ent follow up - should remove foley after discharge - ensure regular bowel movements - needs to have weekly labs drawn with: cbc, vanc trough, and bmp. please fax results to clinic . - needs inr monitored every 1-2 days until stable. - consider restarting lisinopril and long-acting insulin after discharge medications on admission: home meds: -zocor -warfarin -plavix -asa -lisinopril -carvedilol -metoprlol -hydralazine -potassium -protonix -insulin -flonase -listed as taking lasix, iron, vit b12 but pt not taking transfer medications: -vancomycin 1g iv q12 ( - ) -tylenol 650mg q6 -asa 162mg qd -plavix 75mg qd -clotrimazole 1% cream to feet -docusate 100mg qd -iron 325mg qd -flonase -lasix 20mg iv qd -hydralazine 25mg qd -iss with novolog and tid novolog -lantus 52units qhs -metoprolol xl 100mg -omeprazole 40mb -miralax qd -simvastatin 80mg qhs -tramadol prn -morphine prn -zofran prn -nitroglycerin prn -percocet prn discharge medications: 1. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 2. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 6. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous four times a day: per sliding scale (may need standing 70/30 after starts eating). 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 9. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: three hundred (300) mg po daily (daily). 10. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 13. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) gram po daily (daily). 14. vancomycin 500 mg recon soln sig: seven y (750) mg intravenous q 12h (every 12 hours): until . discharge disposition: extended care facility: - discharge diagnosis: bacteremia due to icd infection atrial fibrillation with rapid ventricular response pleural effusion pericardial effusion tracheal stenosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital due to fevers and a bacterial infection from your icd. you were treated with iv antibiotics and will need to continue these antibiotics (vancomycin) after discharge. you also had an electrophysiology study that showed that you do not need to have your icd replaced. you also had endotracheal intubation in preparation for the electrophysiology study. however, you had swelling of your airway and we were unable to take your breathing tube out. you had a tracheostomy placed in order to help you breath on your own. you were on a ventilator for about a week, but were slowly taken off the ventilator. you also had fluid around your left lung and had a tube in your chest to drain the fluid for several days. you also had episodes of a fast irregular heart rhythm and need to take coumadin for as a blood thinner. you should weigh yourself every morning and alert the physician in your facility you also had imaging of your mouth which shows that you have multiple cavities and should have your teeth extracted. you should also have foley removed after discharge and ensure regular bowel movements. changes to your medications: change carvedilol to metoprolol 25mg twice daily change warfarin to 3mg daily change aspirin to 81mg daily add amiodarone 300mg po daily add vancomycin 750mg iv q12h (until ) followup instructions: department: infectious disease when: friday at 10:00 am with: , md building: lm campus: west best parking: garage department: otolaryngology-audiology when: monday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage department: infectious disease when: wednesday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage physician: . department: cardiology date/time: at 01:40p location: , sc clinical ctr, contact: when you are discharged from rehab, please contact your pcp for appointment. please also call the oral surgery department at at . this is very important. you will also be called by dr. in the interventional pulmonary department for a follow-up appointment. they will call you at rehab with an appointment. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more thoracentesis thoracentesis catheter based invasive electrophysiologic testing other bronchoscopy laryngoscopy and other tracheoscopy temporary tracheostomy nonexcisional debridement of wound, infection or burn cardiac mapping replacement of tracheostomy tube removal of lead(s) [electrode] without replacement revision or relocation of cardiac device pocket central venous catheter placement with guidance diagnoses: other primary cardiomyopathies hyperpotassemia unspecified pleural effusion congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation hematoma complicating a procedure atrial flutter percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified pulmonary collapse constipation, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure iatrogenic pneumothorax bacteremia other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation old myocardial infarction long-term (current) use of anticoagulants iron deficiency anemia, unspecified acute and subacute bacterial endocarditis surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation dehydration staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus empyema without mention of fistula dental caries, unspecified other diseases of trachea and bronchus personal history of sudden cardiac arrest infection and inflammatory reaction due to cardiac device, implant, and graft mechanical complication of tracheostomy edema of larynx aspiration of fluid as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure chronic combined systolic and diastolic heart failure 

Answer: The patient is high likely exposed to