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: penicillins attending: chief complaint: fever, chills major surgical or invasive procedure: pacemaker explant insertion of temporary external pacemaker picc line placement r history of present illness: mr. . is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical avr on coumadin, h/o chb s/p ppm who comes with malaise, ha and fever up to 102 with peripheral vision loss. he underwent surgery succesfuly in , which was complicated by recurrent pericardial effusion that was treated with a pericardial window. he was discharged home on and was doing well, able to play golf and purposely losing some weight. six days ago he started noticing fever up to 102, chills, rigors, loss of apetite and night sweats. he almost had no symptoms during the day. he went and saw his pcp 3 days ago who did blood work and sent him home. his pcp labs included gluc 11, bun 8, creat 0.68, na 136, k 4.1, cl 102, co2 26, ca 8.8, prot 6.4, alb 3.4, ap 87, ast 38, alt 34, bil 0.7. ua negative for uti, but with mild proteinuria and keytones. he got blood cultures drawn that came back positive 1/2 bottles (anaerobic) with gpcs in chains and was called to go to the er. . at hospital his vs were stable. he received in vancomycin 1 gm iv once morphine and zofran. wbc 9.7, hct 25, plt 191, no bands. he was transfered to our er for further work up. . in our er his initial vs were t 103.1 f, bp 124/70 bpm, hr 90 bpm, rr 18 x', spo2 96% on ra. his initial exam showed normal jvp, clear lungs, no edema. he received gentamycin 120 mg iv, tylenol po at 6 am, 8 mg of morphine iv, 4 mg of zofran and 5 mg of iv vit k. during his ed stay he reports loss of vision in the left upper visual field in his left eye. stroke service was consulted. repeat ct scan showed 15 mm lesion without any new lesions. minimal perihemorrhagic edema. reconstruction is pending to eval for mycotic aneurysm. ophtalmology evaluated patient and saw no abnormalities after dilation. the differential includes tia, compromised circulation to occipital area, embolic event is also possible. he is admitted to the ccu service. her received 2 ffps. his vs prior to transfer were vs: hr 85, rr 12, bp 109/68, 96% 2l. . of note, he denies any recent dental procedures, skin infections, uri-symptoms, sick contacts, ivdu, changes in his medications (other than stopping toprol xl and ranitidine). no recent travel. <br> on review of systems, he denies 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 denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. <br> cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: - diabetes, - dyslipidemia, - hypertension 2. cardiac history: -cabg: none. -percutaneous coronary interventions: none. -pacing/icd: ppm, 2 leads in place. <br><b>past medical history: </b> complete heart block(ppm) postop dvt in lue following lead extraction hyperlipidemia s/p dual chamber pacemaker placement in s/p replacement of pm generator s/p lead extraction and reimplantation of ppm hernia repair as child s/p avr(mechcanical)ascending aortic arch replacment on with 25-mm st. medical regent mechanical valve secondarily to bicuspid aortic valve diagnosed in 7th grade and progressing ascending aortic aneurysm of 5.4cm at time of surgery. surgery was complicated by tamponade and required subxiphoid pericardial window on . s/p cabg lima-lad in h/o dvt social history: he lives with his wife, daughter, son and son in law in . he works in a shipyard, but denies any exposure to asbestos. he quit smoking 2 years ago and has history of 30-40 pack-year. he denies any current or past alcohol intake or illegal substance use. he plays golf as excercise. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. father had first mi in his 60s and died of emphysema. mother died of a blood clot (unknown location). physical exam: vital signs - temp 97.8 f, bp 123/67 mmhg, hr 77 bpm, rr 26 x', o2-sat 98% 2 l nc general - well-appearing man in nad, oriented x3, comfortable, mood, affect appropriate. heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear, conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi located in 5th intercostal space, midclavicular line. rrr, normal s1, mechanical s2. mild sem rusb radiating towards both carotids. no r/g. no thrills, lifts. no s3 or s4. abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding. abd aorta not enlarged by palpation. no abdominial bruits. extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps), no c/c/e. no femoral bruits. skin - no rashes or lesions. no stasis dermatitis, ulcers, scars, or xanthomas. no osler nodes or signs of embili. lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, cerebellar exam intact, gait not evaluated, normal eye exam on confrontation and 20/20 bilateraly. pertinent results: 10:38am blood wbc-7.6 rbc-3.63* hgb-10.1* hct-29.9* mcv-82 mch-27.7 mchc-33.7 rdw-15.0 plt ct-166 04:30am blood wbc-9.1 rbc-3.62* hgb-9.9* hct-30.7* mcv-85 mch-27.2 mchc-32.1 rdw-14.5 plt ct-173 07:00am blood wbc-8.4 rbc-4.17* hgb-11.6* hct-35.0* mcv-84 mch-27.8 mchc-33.1 rdw-15.0 plt ct-251 06:00am blood wbc-12.5* rbc-3.43* hgb-9.4* hct-28.3* mcv-83 mch-27.4 mchc-33.2 rdw-14.7 plt ct-374 06:02am blood wbc-11.1* rbc-3.32* hgb-9.3* hct-27.0* mcv-81* mch-28.2 mchc-34.6 rdw-14.3 plt ct-356 06:00am blood pt-46.6* ptt-38.9* inr(pt)-5.0* 10:38am blood pt-24.6* ptt-33.5 inr(pt)-2.4* 09:07pm blood pt-14.9* ptt-27.3 inr(pt)-1.3* 10:38am blood esr-45* 10:38am blood ret aut-0.9* 06:00am blood glucose-109* urean-8 creat-0.7 na-136 k-4.4 cl-102 hco3-23 angap-15 04:30am blood glucose-113* urean-6 creat-0.7 na-133 k-4.2 cl-100 hco3-25 angap-12 07:00am blood glucose-101* urean-6 creat-0.6 na-136 k-4.3 cl-97 hco3-31 angap-12 06:00am blood glucose-113* urean-9 creat-1.0 na-129* k-4.4 cl-96 hco3-27 angap-10 06:02am blood glucose-121* urean-10 creat-1.1 na-131* k-4.1 cl-96 hco3-28 angap-11 10:38am blood alt-29 ast-36 ld(ldh)-364* alkphos-56 totbili-0.4 06:30am blood alt-94* ast-60* ld(ldh)-406* alkphos-73 totbili-0.3 06:35am blood alt-94* ast-57* ld(ldh)-414* alkphos-72 totbili-0.3 06:02am blood alt-33 ast-18 ld(ldh)-329* ck(cpk)-28* alkphos-70 totbili-0.3 06:00am blood ctropnt-<0.01 10:38am blood albumin-3.2* calcium-7.9* phos-2.6* mg-1.7 04:30am blood calcium-8.0* phos-2.0* mg-1.9 06:02am blood albumin-3.0* calcium-8.8 phos-4.5 mg-2.1 09:20am blood iron-22* 09:20am blood caltibc-225* vitb12-1376* folate-14.9 ferritn-388 trf-173* 10:38am blood rheufac-13 crp-215.5* blood cultures drawn on the day of admission showed the same culture results. blood culture, routine (final ): beta streptococcus group b. final sensitivities. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . sensitivity testing performed by sensititre. sensitivities: mic expressed in mcg/ml _________________________________________________________ beta streptococcus group b | clindamycin----------- r erythromycin---------- =>4 r penicillin g----------<=0.06 s vancomycin------------ <=1 s anaerobic bottle gram stain (final ): gram positive cocci in chains. reported by phone to at 1715 on . aerobic bottle gram stain (final ): gram positive cocci in chains. ekg : sinus rhythm with atrial sensed and ventricular paced rhythm. since the previous tracing of there is no significant change. cta head: impression: 1. stable 15 mm right frontal parenchymal hematoma with slight increase of peripheral zone of edema; a small underlying mass cannot be entirely excluded. 2. no ct angiographic "spot sign" to suggest impending enlargement of hemorrhage. 3. no evidence of cerebral venous thrombosis. 4. no new focus of hemorrhage. 5. patent anterior and posterior circulation vasculature without evidence of vascular malformation or aneurysm larger than 2 mm. tee : 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/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. a bileaflet aortic valve prosthesis is present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is a trivial/physiologic pericardial effusion. impression: no vegetations seen on mitral valve, tricuspid valve, pulmonic valve. there is small (3mm) relatively fixed echodensisty adjacent to the aortic root side of the mechanical aortic valve near the non-coronary cusp which was present in the immediate post operative tee on and is likely a suture. compared with the prior tee study (images reviewed) of there are no significant changes. . tee : the left atrium is markedly dilated. the left atrium is elongated. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage.there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is inferolateral and inferior wall hypokinesis but overall left ventricular systolic function is normal (lvef>55%). right ventricular systolic function is normal with good free wall contractility.the aortic root is moderately dilated at the sinus level. a mechanical aortic valve prosthesis is present. the valve appears to be well-seated without perivalvular leaks, however, the individual prosthetic leaflets cannot be adequately assessed due to artifact. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). peak/mean gradients are 64/36 mmhg. mild-moderate aortic regurgitation is seen. there is a mobile 7mm x 6 mm mass on the upstream surface of the aortic valve, most likely on the right cusp. this is also the area which shows the ai. it is consistent with a vegetation. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. there is no pericardial effusion. . tte : the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated at the sinus level. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal disc motion and transvalvular gradients. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior focused study (images reviewed) of , the pericardial effusion has resolved. the absence of endocarditis on a transthoracic echo does not exclude the diagnosis if clinically suggested. if clinically suggested, a tee may be more sensitive for identifying vegetations. . cerbral angiography: impression: no evidence of aneurysm, arteriovenous malformation, or active extravasation. in particular, no abnormality identified in the region of the right frontal parenchymal hemorrhage. . leni : -scale and doppler son of bilateral common femoral, superficial femoral, and popliteal veins were performed. there is appropriate compressibility, flow, and augmentation. impression: no evidence of dvt. . picc: impression: uncomplicated ultrasound and fluoroscopically guided double lumen picc line placement via the right brachial venous approach. final internal length is 37 cm, with the tip positioned in svc. the line is ready to use. . lle u/s: study: left lower extremity soft tissue ultrasound. findings: multiple grayscale images of the left groin, left thigh and left calf demonstrate no fluid collection. impression: no evidence for fluid collection. . cxr : lung volumes are normal. lungs are clear without focal consolidations. heart size is normal. hilar and mediastinal silhouettes appear stable. no pulmonary edema, pleural effusions or pneumothoraces are identified. pacemaker lead projects over right ventricle. two radiopaque densities are seen projecting over right ventricle, which may represent fragmented leads, and are unchanged since study. right picc line tip is obscured by pacemaker lead, it is visible at upper to mid svc. impression: no acute cardiopulmonary process. . ct l-spine 1. no evidence of epidural or paraspinal abscess in the lumbosacral spine. 2. mild degenerative changes of the lumbar spine, worse at l4-l5 level, with discogenic disease and osteophytes causing thecal sac indentment and neural foraminal narrowing bilaterally. attending note: although ct without contrast is not sensitive to detect epidural disease, no obvious deformity of thecal sac seen to suggest abscess. bilateral moderate foraminal narrowing seen at l4-5. brief hospital course: mr. . is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical avr on coumadin, h/o chb s/p ppm who comes with malaise, ha and fever up to 102 with peripheral vision loss and positive blood cultures for gpcs. # endocarditis: the patient came from an outside hospital with positive blood cultures. he was immediately started on vancomycin and gentamicin. the vancomycin was then switched to ceftriaxone and he was continued on the gent. he had an initial tee that showed no evidence of a thrombus or vegetation in the leads. ct surgery did not want to intervene at this time as he was stable. his first 3 blood cultures all returned positive for group b streptococcus that was sensitive to ceftriaxone. the patient had a ct head at an osh that showed a frontal lobe hemorrhage, this was followed by ct and showed small interval change after the first. a cerebral angiogram was also obtained per neurology which showed no evidence of mycotic aneurysm, or other irregularities. neurology recommended re-imaging only if there was change on physical exam, which there was not. the patient had repeated fevers spikes so a tte was done which showed no evidence of vegetation. a repeat tee was done which showed a 7mm x 6 mm vegetation on the aortic valve. ct surgery was reconsulted and again deferred intervention until he had a longer treatment with abx. the patient had his pacer and leads explanted with ep and a temporary external pacemaker was placed. ct a/p was obtained which showed no focus of infection in the abdomen. he developed intermittent back and left leg pain which id was concerned for abscess/phlegmon. a ct l-spine showed no evidence of abscess, discitis, or osteomyelitis. u/s of the left thigh and dvt studies were obtained which showed no evidence of fluid collection or dvt. it was thought this pain was msk and was managed with pain control and hot packs. the patient had a picc line inserted under ir with no complications. his gentamicin was stopped in house after a 2 week course and he was to continue ceftriaxone for a total of 6 weeks. follow-up was scheduled with dr. on . # embolic stroke - the patient had a head ct at an osh that showed a frontal lobe hemorrhage. the patient's coumadin was held and he had a repeat ct head and cta which showed a small interval increase in hemorrhage from previous. a cerebral angiogram showed no irregularities as above. neurology recommendations were to hold his coumadin for 1 week and then start a heparin drip to bridge to a therapeutic inr. he was also started on aspirin 81mg daily. inr therapeutic at 2.3 on coumadin 12mg daily on . pt discharged. . # follow up: pt requires ct abdomen for evaluation of abscesses septic emboli from endocarditis as outpatient. cardiology device clinic at hospital for evaluation of device within 1 week following discharge. id f/u per appts. inr checks with f/u with pcp, home inr machine and titrate medication based on pcp . cardiology f/ per appt. ct surgery f/u per appt. medications on admission: aspirin 81 mg daily colace 100 mg po bid coumadin 10 mg 3 days per week and 11 mg 4 days per week simvastain 40 mg, pcp switching to discharge medications: 1. ceftriaxone 2 gram recon soln sig: two (2) gram intravenous every twenty-four(24) hours for 27 days. disp:*qs 27 doses* refills:*0* 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. warfarin 10 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 6. warfarin 2 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. discharge disposition: home with service facility: of southern discharge diagnosis: endocarditis - av vegetation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization. you were admitted for infection of your aortic valve and blood stream. you were started on antibiotics to treat the infection and it was decided by the cardiology and electrophysiology teams to remove your pacemaker as well since it was a potential focus of infection. a temporary pacemaker was placed in your neck until you finish your course of antibiotics and can have a new pacemaker replaced. you were also started on blood thinning medications called warfarin and iv heparin. you became therapeutic on wafarin on . dr. advised you to go rehab with your temporary pacemaker until surgical replacement of your pacer could occur after you finished the course of iv antibiotics. the reason for this is your heart rhythm is pacer dependent and if your pacer is disrupted, it could result in lifethreatening consequences. you declined discharge to long-term acute care and stated preference to be discharged to home. . we recommend that you get an abdominal ct scan to evaluate for possible abscess formation as an outpatient. please schedule this through your pcp . . the following changes were made to your medications: started ceftriaxone 2 gm iv q24h day 1 increased coumadin 12mg daily . please follow up with your physicians at the appts states below: followup instructions: department: cardiac surgery when: thursday at 1:45 pm with: , md building: lm campus: west best parking: garage department: cardiac services when: tuesday at 3:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage . dr. wants pt to see device clinic 2 weeks post op according to ( dr. ) when she spoke to him. department: infectious disease when: tuesday at 9:00 am with: flash, md building: lm bldg () campus: west best parking: garage department: infectious disease when: tuesday at 10:30 am with: flash, md building: lm bldg () campus: west best parking: garage . please follow up with your cardiology device clini at hospital, call for appointment within 1 week of discharge. call for appt: . inr checks on your warfarin medication: please check levels using your home inr machine. follow up with your pcp who will titrate your medication appropriately. procedure: venous catheterization, not elsewhere classified diagnostic ultrasound of heart arteriography of cerebral arteries insertion of temporary transvenous pacemaker system revision or removal of pacemaker device diagnoses: anemia, unspecified aortocoronary bypass status other and unspecified hyperlipidemia heart valve replaced by other means atrioventricular block, complete long-term (current) use of anticoagulants cardiac pacemaker in situ acute and subacute bacterial endocarditis personal history of venous thrombosis and embolism cerebral embolism with cerebral infarction congenital insufficiency of aortic valve streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group b pain in limb septic pulmonary embolism 

Answer: The patient is high likely exposed to