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: this is an 85-year-old male with an extensive cardiac history significant for aortic valve replacement, coronary artery bypass graft, peripheral vascular disease (status post femoral-popliteal bypass), required removal of the pacemaker in , and type 2 diabetes mellitus who was transferred to from an outside hospital for placement of a new pacemaker for intermittent bradycardia consistent with mobitz type 2. the patient was admitted to the outside hospital on the patient also has a history of pancreatitis, and his amylase and lipase were increased on admission. the patient was reported to have made a rapid recovery, and his diet was advanced on ; and he reportedly tolerated a soft die . cardiology was consulted and recommended further intervention for heart block. on admission, the patient experienced to left chest pressure. it was different from his previous anginal and pancreatic pain. he denied radiation to the back or extremities. there was no improvement with sublingual nitroglycerin times three. he was given morphine which resulted in nausea and vomiting. a nitroglycerin drip was started by the nurse improvement. electrocardiogram remained unchanged without st changes, q waves, or inversions. his blood pressures in the bilateral upper extremities were equal. cardiac enzymes were negative. a chest x-ray was unchanged from his previous study. his amylase and lipase were still noted to be evaluated. otherwise, the patient stated that his gastrointestinal discomfort was improved. he was tolerating solids and had regular bowel movements. he denied shortness of breath, fevers, and chills. past medical history: 1. aortic stenosis; status post aortic valve replacement (a bjork-shiley valve) in . 2. coronary artery disease; status post coronary artery bypass graft in ; pacemaker for syncope in with endocarditis in with resultant pacemaker removal. 3. peripheral vascular disease; status post right below-knee amputation; status post left femoral bypass in with revision; status post left great toe amputation. 4. status post cholecystectomy. 5. status post cerebrovascular accident with right facial droop and right hemiparesis. 6. idiopathic pancreatitis. 7. history of partial small-bowel obstruction. 8. history of aspiration pneumonia. 9. hiatal hernia. 10. upper gastrointestinal bleed. 11. hypertension. 12. insulin-dependent diabetes mellitus (which was adult-onset). medications on admission: 1. persantine 25 mg p.o. b.i.d. 2. norvasc 2.5 mg p.o. b.i.d. 3. accupril 10 mg p.o. b.i.d. 4. bextra 10 mg p.o. q.d. 5. enteric-coated aspirin 325 mg p.o. q.d. 6. multivitamin one tablet p.o. q.d. 7. colace 100 mg p.o. b.i.d. 8. celexa 20 mg p.o. q.d. 9. a regular insulin sliding-scale. 10. nph 4 units subcutaneously q.a.m. and 1 unit subcutaneously q.p.m. allergies: an allergy to zocor (which increases his liver function tests). digoxin (causes nausea and vomiting). pepcid (gives him mental status changes). social history: social history is negative for ethanol and tobacco. he was a professional ballerina and lives with his wife who is an astrophysicist. physical examination on presentation: physical examination on admission revealed temperature was 99.1, blood pressure was 176/68, heart rate was 66, oxygen saturation was 98% on room air. blood sugar was 194. he was alert and oriented times three, in mild discomfort. head, eyes, ears, nose, and throat revealed normocephalic and atraumatic head. a right-sided facial droop was noted. bilateral bibasilar crackles on lung examination. no wheezes, rhonchi, or rales. he had a regular rate with intermittent dropped beats. he had a 3/6 systolic ejection murmur. his abdomen was soft and diffusely tender. extremities were notable for a right below-knee amputation and left bypass scar. no edema with normal perfusion. pertinent laboratory values on presentation: laboratories revealed white blood cell count was 9.6, hematocrit was 35.3, and platelets were 209. differential with 58% neutrophils. sodium was 142, potassium was 3.8, chloride was 107, bicarbonate was 25, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 111. calcium was 8.8, magnesium was 1.7, phosphorous was 2.5. ast was 25, alt was 14, alkaline phosphatase was 86, total bilirubin was 0.2, amylase was 203, and lipase was 369. creatine kinase was 124. ck/mb was 3. troponin i was less than 0.3. radiology/imaging: electrocardiogram with a heart rate in the 60s, prolonged p-r interval, poor r wave progression. no st changes. a chest x-ray anterior/posterior film with appropriate mediastinal shadow compared with previous study. hospital course: the patient was initially treated for rule out myocardial infarction due to significant coronary artery history. initial cardiac enzymes were negative, and the electrocardiogram was without acute changes. he was continued on his ace inhibitor, norvasc, and nitroglycerin drip for blood pressure control. he was also continued on aspirin. according to an echocardiogram in revealed he did have an ejection fraction of greater than 55%, but he was noted to have intermittent bradycardia to the 30s on telemetry while sleeping. he was planned for a possible pacemaker placement the following morning. in light of his recent episode of pancreatitis with still elevated amylase and lipase, the patient was again made nothing by mouth due to his abdominal pain. in addition, he was started with gentle hydration. overnight, the patient continued to have increased abdominal pain which was similar to his previous pancreatitis. he also had nausea and vomiting with greenish/yellowish output. it was determined by electrophysiology not to place a pacemaker at this time in light of the previous history of endocarditis that required pacemaker removal. since the patient was not going to receive a pacemaker at this time, and in light of his continued nausea and vomiting (consistent with pancreatitis), the patient was transferred from the cardiology medicine service to the general medicine service. on the medicine service, he was continued as nothing by mouth with intravenous hydration and intravenous dilaudid as needed for pain. electrophysiology continued to follow the patient in light of his history of atrioventricular block and likely pacemaker placement once acute pancreatitis resolved and infectious disease cleared him. he was managed supportively for pancreatitis. to evaluate his risk for pacemaker, they recommended following routine blood cultures. an endoscopic retrograde cholangiopancreatography was offered to evaluate for stone causing pancreatitis, which the patient refused. thus, he was continued with just supportive management. on , his diet was slightly advanced to ice chips and sips of fluids. overnight, he started vomiting and had increased nausea. on the morning of , he had increased shortness of breath and respiratory distress. his temperature was 99.7 axillary, blood pressure was 233/80, respiratory rate was approximately 25, heart rate was 90 on electrocardiogram. concerning for a possible gastric volvulus or obstruction. of note, his bicarbonate was noted to have dropped to 9. thus, he was managed with a nasogastric tube with several hundred cc of bilious fluid out. he was also given bicarbonate and transferred to the unit. in a discussion on this day, the patient stated that he was full code. planned to get an abdominal computed tomography. in addition, he was put on levofloxacin and flagyl, per infectious disease service recommendations in this setting. the patient was fluid resuscitated, received frequent arterial blood gases and chemistry-7 panels to assess for improvement of his acidosis. an nasogastric tube was sufficient in addition to the fluids to decompress his stomach with resolution of his symptoms. the abdominal computed tomography showed an atrophic pancreas without necrosis of fat stranding, and the vasculature to the gut was with preserved flow. some diverticula were noted. the contrast passed minimally through the gut. there were stones and no ductal dilatation of the gallbladder. a follow-up chest x-ray demonstrated right middle lobe and right lower lobe opacity; possibly an aspiration pneumonia. he was continued on levofloxacin and flagyl. he remained afebrile. while in the unit on , the patient was noted to be ruling in for a non-q-wave myocardial infarction; although, he did not have any chest pain. he was started on a heparin drip, and his creatine kinases were monitored for a peak and trough. he was also continued on levofloxacin and flagyl for his aspiration pneumonia. due to his baseline atrioventricular block, no beta blocker was initiated. over time, the metabolic acidosis resolved with intravenous fluids and stomach decompression only. his diet was slowly advanced to clears while in the unit. on , he was determined to be stable with a non-q-wave myocardial infarction on aspirin and intravenous heparin. he was scheduled for an echocardiogram. for the aspiration pneumonia, he was continued on levofloxacin and flagyl. at this point, for this pancreatitis, the enzymes had normalized, and a swallow study was recommended to determine whether it was safe to advance his diet as tolerated or tube feeds in light of his aspiration pneumonia. he had a peripherally inserted central catheter line ordered to be placed by radiology, and he was stable to be discharged to the floor on . on , a modified barium swallow study was obtained which demonstrated that the patient had moderate oral, severe pharyngeal, dysphagia characterized by reducible formation; anterior/posterior, transit and pharyngeal, residue, as well as pharyngeal delay and swallowing initiation which resulted in gross aspiration with poor sensory awareness, with all consistencies assessed. a chin tuck maneuver effectively eliminated aspiration with only nectar-thick liquids and pureed solids with a limited bolus size. a chin tuck was not effective at limiting aspiration with thin liquids. in addition, laryngeal penetration occurred with nectar-thick and purees while using the chin tuck. thus, the patient had clinical evidence of gross and intermittently silent aspiration and remained at high risk for aspiration which was moderately lessened with strict strategy use. the recommendations were nectar-thick liquids, pureed solids, and pills crushed and pureed, bolt upright with one-to-one supervision at all meals, and chin tuck to chest for all sips. all liquids were to be given via teaspoon with no cups or straws. he was to swallow twice for every bite and sip. due to the continued risk for high aspiration, it was determined he would probably need placement for long-term nutrition and hydration such as a percutaneous endoscopic gastrostomy tube to meet his nutritional needs. the patient stated he wanted to continue taking oral foods. the patient continued to be managed for his acute issues while awaiting potential pacemaker placement. he continued to have atrioventricular block, bigeminy, as well as trigeminy on telemetry, and he also continued to have issues with elevated systolic blood pressures; occasionally in the 200s, for which he was titrated up on hydralazine q.6h. as needed in addition to a nitroglycerin paste sliding-scale. no beta blocker were used due to his underlying disease. he was continued on the levofloxacin and flagyl. of note, on , his hematocrit was noted to be 28.5. in light of his cardiac history, he was transfused 2 units of packed red blood cells with an appropriate response. he continued to be monitored symptomatically in preparation for his possible pacemaker placement. on , the patient had a follow-up chest x-ray in light of his aspiration pneumonia. on follow-up, he was noted to have a right-sided pneumothorax; probably secondary to several attempts for venous access via right internal jugular and right subclavian without success. thus, thoracic surgery was consulted for chest tube placement. they placed a pigtail catheter. repeat chest x-rays serially demonstrated continued improvement in the size of the pneumothorax. the patient remained asymptomatic with this pneumothorax. of note, the chest tube was noted to be draining greater than 1300 cc of fluid in the first 16 hours. it was sent for analysis and culture. the chest tube continued to have decreased drainage over the next few days. he continued to remain afebrile with a normal white blood cell count during this time. mr. continued to have occasional episodes of nausea and vomiting which precluded appropriate oral intake. thus, he was initiated on total parenteral nutrition on . on , it was noted that it was possible that the chest tube may have been moved out of the pleural space. since cardiothoracic surgery would not be able to reposition it, it was determined to just remove it since there was almost complete resolution of the pneumothorax and significantly decreased fluid drainage. the chest tube was removed on . the patient continued to be afebrile and felt better. the patient was continued on levofloxacin and flagyl intravenously for his aspiration pneumonia until ; for a total of a 14-day course. on , a percutaneous endoscopic gastrostomy tube was placed by gastroenterology for improved nutrition. feeds were started without complications on . due to his continued hypertension, hydralazine continued to be titrated up for appropriate control. in preparation for pacemaker placement tentatively scheduled for , it was determined that the peripherally inserted central catheter line would need to be removed in order to decrease the infection risk. the peripherally inserted central catheter needed to be removed greater than 24 hours prior to pacemaker placement. the peripherally inserted central catheter line was removed on . the peripherally inserted central catheter tip was sent for culture. the patient was made nothing by mouth for a planned pacemaker placement for . of note, the peripherally inserted central catheter tip culture came back with greater than 15 colonies of coagulase-negative staphylococcus. thus, the patient's pacemaker placement was deferred. surveillance blood cultures were sent today. based on his previous infection risk, it was determined to monitor the surveillance blood cultures sent that day, and if they remained negative for 48 hours, and the patient remained clinically stable, it could be placed (at the earliest) on . thus, the pacemaker placement was cancelled on . the patient continued to remain stable without any active issues; off levofloxacin and flagyl for the aspiration pneumonia after a 14-day course. the patient continued to tolerate tube feeds without complications. the cultures remained negative times 48 hours, and the patient had a pacemaker placement performed on . the patient tolerated the procedure without complications. he was given vancomycin for prophylaxis prior to the procedure. the patient received a dual-chamber and rate-responsive pacemaker (serial number ). thus, he received a dual-mode, dual-pacing, dual-sensing pacemaker without complications. the pacemaker was made by . discharge disposition: the patient was discharged home on since he was stable status post procedure. he was discharged home with home health services. in addition, he was sent home with continued tube feeds in order to insure adequate nutrition. medications on discharge: 1. heparin subcutaneous 5000 units q.12h. 2. prochlorperazine 10 mg p.o. q.4-6h. as needed. 3. protonix 40 mg p.o. q.d. 4. docusate liquid 100 mg p.o. b.i.d. as needed. 5. citalopram 20 mg p.o. q.d. 6. nph insulin 4 units subcutaneously q.a.m. and 2 units subcutaneously q.p.m. 7. a regular insulin sliding-scale. 8. aspirin 325 mg p.r. q.d. 9. furosemide 400 mg p.o. q.d. 10. isosorbide mononitrate 20 mg p.o. t.i.d. 11. bisacodyl 10 mg p.r. q.d. as needed. 12. lorazepam 0.25 mg p.o. q.4-6h. as needed. 13. sublingual nitroglycerin 0.3 mg as needed. 14. persantine 25 mg p.o. b.i.d. 15. accupril 5 mg p.o. b.i.d. 16. multivitamin one tablet p.o. q.d. 17. keflex 500 mg p.o. (times six doses). discharge instructions/followup: 1. the patient was instructed to follow up with his primary care physician (dr. ) and with his cardiologist (dr. ) as determined by both of these physicians. 2. in addition, the patient was instructed to follow up with his primary care physician in his . condition at discharge: condition on discharge was improved status post pacemaker placement. discharge status: discharge status was to home with , physical therapy, occupational therapy, speech therapy, and tube feeds. discharge diagnoses: 1. atrioventricular block. 2. status post pacemaker placement. 3. status post a non-q-wave myocardial infarction. 4. aspiration pneumonia. 5. pneumothorax. 6. metabolic acidosis; likely secondary to partial small-bowel obstruction. , m.d. dictated by: medquist36 d: 18:28 t: 04:50 job#: procedure: insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified other endoscopy of small intestine enteral infusion of concentrated nutritional substances initial insertion of dual-chamber device initial insertion of transvenous leads [electrodes] into atrium and ventricle percutaneous [endoscopic] gastrostomy [peg] diagnoses: acidosis subendocardial infarction, initial episode of care congestive heart failure, unspecified acute kidney failure, unspecified pneumonitis due to inhalation of food or vomitus iatrogenic pneumothorax acute pancreatitis mobitz (type) ii atrioventricular block 

Answer: The patient is high likely exposed to