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: the patient is an 82-year-old female with a past medical history significant for aortic stenosis (status post aortic valve replacement), hypertension, and hypercholesterolemia who was recently discharged from on following evaluation and treatment for a gait instability secondary to embolic cerebrovascular accident in the setting of a ruptured mitral valve chordae tendinae (and valvular vegetations on transesophageal echocardiogram per discharge summary) who presents from rehabilitation with hypotension. per the rehabilitation facility, the patient had a decreased appetite, was diaphoretic, soaked through bed clothes, and was confused. the patient reported feeling warm with chills. vital signs at rehabilitation revealed the patient's temperature was 101.2 degrees fahrenheit, her blood pressure was 78/40s, her heart rate was 114, and her oxygen saturation was 91% on 3 liters. the patient was given levofloxacin 500 mg times one and transferred to for evaluation. in the emergency room, the patient was hypotensive to 92/58, with a rectal temperature of 102.6 degrees fahrenheit, and her oxygen saturation was 97% on 2 liters via nasal cannula. the patient was given 3 liters of normal saline. the patient remained hypotensive with a systolic blood pressure of approximately 85 and was triaged per sepsis protocol. the patient was given empiric vancomycin and flagyl. a central line was placed. per the patient's family, she had been lethargic and confused with hallucinations, not eating for the last two to three days, and with positive wheezes. the patient reports feeling "blah" the last day or so with fevers and shakes. no chest pain, palpitations, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, or constipation. she had a positive rash of unknown cause. no other complaints except for general fatigue. vital signs on arrival to the medical intensive care unit revealed the patient's temperature was 99 degrees fahrenheit orally, her heart rate was 76 to 80, and her blood pressure was 96 to 99/40 to 43, mean arterial pressure was 60 to 61, her respiratory rate was 24 to 34, central venous pressure was 10 to 11, and her oxygen saturation was 97% to 99% on 3 liters via nasal cannula. in general, the patient was an elderly female lying in bed who was oriented to person and place. the neck was supple with a right internal jugular surrounding hematoma. head, eyes, ears, nose, and throat examination revealed the oropharynx was dry and with no lesions. cardiovascular examination revealed sinus. there was holosystolic murmur. there were no rubs or gallops. respiratory examination revealed the lungs were clear to auscultation bilaterally. there were no wheezes or rhonchi. the abdomen was soft with active bowel sounds. the abdomen was nontender and nondistended. there was no hepatosplenomegaly appreciated. extremity examination revealed 1+ dorsalis pedis pulses bilaterally. extremities were warm to palpation. the skin was diaphoretic with a maculopapular rash on the thighs, torso, and shoulders bilaterally. pertinent laboratory values on presentation: laboratories on admission were notable for a white blood cell count of 12.1, her hematocrit was 35.7, and her platelets were 175. liver function tests were within normal limits. her lactate was 2.2. urinalysis was positive for nitrites, trace ketones, trace leukocytes, 11 to 20 white blood cells, occasional bacteria, and 3 to 5 epithelial cells (catheterized). the urine culture was pending. the blood cultures were pending. past medical history: 1. aortic stenosis; status post porcine aortic valve replacement. 2. hypertension. 3. hypercholesterolemia. 4. coronary artery disease. 5. bilateral cataract surgery. 6. status post appendectomy. 7. cerebrovascular accident. 8. ruptured mitral valve chordae. 9. gait instability. 10. supraventricular tachycardia. medications on admission: (at rehabilitation) 1. aspirin 81 mg by mouth once per day. 2. colace 100 mg by mouth once per day. 3. lescol 20 mg by mouth once per day. 4. lasix 20 mg by mouth once per day. 5. prevacid 30 mg by mouth once per day. 6. multivitamin. 7. senna two tablets by mouth once per day. 8. zoloft 50 mg by mouth once per day. 9. coumadin (with a goal inr of 2 to 3). 10. lopressor 25 mg by mouth once per day. 11. levofloxacin 500 mg times one. 12. trazodone 25 mg by mouth at hour of sleep. allergies: allergies include penicillin, bactrim, and intravenous dye. summary of medical intensive care unit course: the patient was treated in the medical intensive care unit through . while in the medical intensive care unit, she was deemed to likely have culture negative endocarditis. in concert with the infectious disease service, the plan was for six weeks of antibiotics. she was originally treated with levaquin and vancomycin. a transthoracic echocardiogram on showed an ejection fraction 65%, severe left ventricular hypertrophy, aortic valve replacement which was well seeded, 3+ mitral regurgitation, and a torn mitral tendon. a transesophageal echocardiogram from could not rule out vegetations. on a transesophageal echocardiogram showed partial flailed mitral leaflets, probable small vegetations of the anterior mitral valve leaflets, and moderate-to-severe mitral regurgitation. there was no evidence of thrombus. given this history, levaquin had been added with the assumption that this was either culture negative endocarditis or a situation of suboptimal cultures where cultures had been taken after receiving antibiotics; thus, rendering the cultures sterile. after originally receiving vancomycin and gentamicin on the infectious disease service recommended the addition of levaquin which was continued until the patient developed a rash on . this rash was in the context of recently starting captopril two days prior to improve afterload reduction in the setting of severe mitral regurgitation. captopril was stopped as was levaquin in concert with a discussion with dermatology who believed this to be a drug rash and these the two the most likely offenders. the patient also developed atrial fibrillation with a rapid ventricular response in the medical intensive care unit which was treated with amiodarone and diltiazem. the amiodarone load resulted in spontaneous conversion to a sinus rhythm on . the patient was continued on amiodarone throughout the rest of her admission with no reversion to atrial fibrillation. concise summary of hospital course by issue/system: 1. endocarditis issues: the patient was treated with vancomycin and gentamicin for part of her admission due to concern over a levaquin allergy. levaquin was restarted on with no resumption of a rash. the patient was afebrile at the time of discharge as she had been for at least one week. this endocarditis was either culture negative or improperly cultured; infectious endocarditis per the infectious disease service. either way, the treatment was to be six weeks of antibiotics with vancomycin and levaquin on discharge with doses of 1 gram intravenously once per day and 500 mg by mouth once per day; respectively. in addition, the patient had an equivocal bartonella antibody result with equivocal bartonella henselae igg (). will repeat per infectious disease service instructions. unlikely that the patient has bartonella acutely as she had no risk factors (per infectious disease consultation). 2. rhythm issues: the patient was in atrial fibrillation. diltiazem was initiated in the emergency room, but it was stopped secondary to insufficient rate control. the patient was loaded with amiodarone and controlled once the transesophageal echocardiogram showed no emboli. beta blockade was changed to an ace inhibitor on transfer from the medical intensive care unit on . on captopril was discontinued as it was ? a cause of the drug rash. the patient remained in a sinus rhythm with abundant ventricular ectopy on telemetry at the time of discharge. the patient was continued on coumadin throughout the hospitalization with a brief period of heparinization for percutaneous endoscopic gastrostomy tube placement given paroxysmal atrial fibrillation and the risk of further embolic cerebrovascular accident. 3. pump issues: the patient had a normal ejection fraction of 65% per transthoracic echocardiogram on . however, the patient had severe mitral regurgitation. given this finding, the patient received afterload reduction initially with captopril which was discontinued secondary to ? cause of drug rash and then started on an angiotensin receptor blocker (valsartan 80 mg by mouth every day). the patient's blood pressure remained well controlled, and her rash disappeared. there was no rash at the time of discharge. the patient was initially diuresed using lasix as needed to keep the lungs as dry as possible. at the time of discharge, the lungs were clear to auscultation bilaterally and the patient had not required lasix for over one week; largely secondary to minimal oral intake. 4. anemia issues: the patient's hematocrit goal was greater than 30. the patient received two blood transfusions during her admission. of note, the patient has alloantibodies (fyb/jka antibodies) which require her to receive matched red blood cells. this is important for any future transfusions. emergent transfusions of unmatched o negative blood could result in hemolysis and a drop in hematocrit. 5. respiratory issues: the patient was initially on oxygen via nasal cannula which she did not require at the time of discharge. the patient has a history of a partial left lobectomy for a benign process. 6. cerebrovascular accident issues: the patient had multiple small infarctions on magnetic resonance imaging. a magnetic resonance imaging/magnetic resonance angiography performed on showed small acute infarctions both corona radiata, right vasoganglia, and left parietal cortical region, moderate-to-severe changes in small vessel disease in the periventricular region, with chronic lacunar infarctions in the vasoganglia and corona radiata bilaterally. the magnetic resonance angiography was normal except for a nonvisualized distal right vertebral artery which could be secondary to artery ending in the posterior/inferior cerebellar artery. a carotid ultrasound revealed right internal carotid artery with 60% to 90% stenosis, the right vertebral artery was not visualized, the left internal carotid artery with less than 40% stenosis, and left antegrade flow (vert). a repeat magnetic resonance imaging of the brain was performed on per neurology recommendations which showed multiple areas of evolving infarctions (hyperintense of diffusion). diffusion showed no new areas suggesting infarction on . flare showed numerous lesions consistent with small vessel ischemic infarctions as described. magnetic resonance imaging showed no evidence of large branch occlusions and no identification of small vessels consistent with lesions. there were also numerous small vessel distribution infarctions, but none new since . given this, per prior consultation for the cardiothoracic surgery plan of waiting for six weeks of antibiotics to be completed prior to consultation for cardiothoracic surgery, was not accelerated as the patient was not showing new infarctions; at least as accessible through the imaging available to us. 7. rash issues: the rash first appeared on in the setting of greater than a 1-week use of levaquin and a 3-day use of captopril. secondary to a dermatology consultation, this rash was believed consistent with a drug reaction. the plan was to discontinue the captopril and transiently discontinue levaquin. the levaquin was restarted on with no recurrence of this drug rash. 8. nutritional issues: the patient's oral intake dwindled over the course of this admission. she originally was eating in the medical intensive care unit and by day 18 her poor oral intake continued. the patient was periodically given d-5 half normal saline to maintain her fluid status. given that we believed this poor oral intake to be a transient problem, she was originally planned to have radiology pass a very thin nasojejunal tube not available on the floor prior to disposition to a skilled nursing facility for intravenous antibiotics. due to emergencies in the radiology department, this tube could not be placed for several days. therefore, a nasojejunal tube was inserted on . prior to this, the nutrition service had been consulted and followed the patient. finally, the patient was recommended to start tube feeds prior to ordering radiology insertion of nasojejunal tube. the goal was also to continue oral intake as tolerated and replete electrolytes as needed. on the patient's family requested that a feeding tube be inserted (percutaneous endoscopic gastrostomy tube) given that they believed that the patient would require exogenous feeding for a long period. thus, the nasojejunal tube placement was cancelled, and a percutaneous endoscopic gastrostomy tube was ordered; requiring wait for inr to be less than 1.5 per gastroenterology recommendations. the patient removed her nasojejunal tube on and refused reinsertion initially. however, the tube was reinserted the next day after she was prevailed upon to change her mind. the patient removed this tube again. a dobbhoff tube was reinserted over the weekend (on ). the patient removed this tube the next day (on ) along with her foley catheter and was found out of bed. given her refusal to reinsert, we decided to wait for percutaneous endoscopic gastrostomy tube the following day. a percutaneous endoscopic gastrostomy tube was inserted on and tube feeds resumed through this percutaneous endoscopic gastrostomy tube early in the morning on . the patient tolerated the procedure well; although she was unhappy with the need for a feeding tube and initially refused usage of it. 9. change in mental status and mood issues: the patient had an increasingly flat affect over the course of her admission with dwindling spontaneous speech and movement. the psychiatry team was consulted on (requested on ). psychiatry's impression was that there was no clear psychiatric illness and that the presentation was likely secondary to medical illness and neurologic sequelae of cerebrovascular accidents. the presentation was termed an apathetic syndrome, not a depressive one, related to several acute infarctions; most notably the right vasoganglia infarction. given that it is exceedingly difficult to reverse apathy, and that the stimulant (ritalin had been started several days prior) as the appropriate choice of as we had already performed, a success rate is also quite low. in this case, the patient had a lot of ectopy, and so the risk of continuing ritalin therapy outweighed the potential benefit. the psychiatry service also believed that it was never clear that the patient ever needed zoloft and that this medication would not reverse apathy even if it was increased, the attending stopping zoloft. both zoloft and ritalin were stopped on . secondary to prevention of coronary artery disease, the patient was continued on a statin and restarted on aspirin after her percutaneous endoscopic gastrostomy tube was placed. discharge disposition: the patient was to be sent to a skilled nursing facility; likely rehabilitation or at the time of this dictation. discharge diagnoses: 1. endocarditis. 2. mitral valve rupture. 3. coronary artery disease. 4. atrial fibrillation (paroxysmal). 5. apathy secondary to multiple cerebrovascular accidents. 6. history of cerebrovascular accidents. 7. mitral regurgitation. 8. poor oral intake. medications on discharge: 1. amiodarone 200 mg by mouth twice per day. 2. enteric-coated aspirin 325 mg by mouth every day. 3. colace 100 mg by mouth twice per day. 4. iron sulfate 325 mg by mouth once per day. 5. coumadin (goal inr of 2 to 3). 6. levofloxacin 500 mg by mouth q.24h. (through ). 7. miconazole powder 2% one application topically four times per day as needed. 8. multivitamin one tablet by mouth once per day. 9. nystatin one application topically four times per day as needed. 10. pravastatin 20 mg by mouth once per day. 11. sarna lotion topically as needed. 12. senna two tablets by mouth once per day. 13. vancomycin 1 g intravenously q.24h. 14. tylenol as needed. 15. dulcolax by mouth/per rectum as needed. 16. lansoprazole 30 mg by mouth once per day. 17. valsartan 80 mg by mouth once per day. condition at discharge: the patient was discharged in stable condition. discharge status: the patient was to be discharged to a skilled nursing facility. discharge instructions/followup: 1. the patient was instructed to follow up with her primary care physician (dr. within one to two weeks. 2. the patient was instructed to follow up with dr. (from cardiothoracic surgery) vis-a-vis mitral valve replacement on . , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] diagnoses: coronary atherosclerosis of native coronary artery pure hypercholesterolemia urinary tract infection, site not specified unspecified septicemia atrial fibrillation septic shock acute and subacute bacterial endocarditis heart valve replaced by transplant cerebral artery occlusion, unspecified with cerebral infarction 

Answer: The patient is high likely exposed to