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: advil / aspirin attending: chief complaint: intermittent bradycardia, hypoxia, chest pain with twi and trop leak in setting of infective endocarditis major surgical or invasive procedure: 1. aortic valve replacement with a size 23-mm st. mechanical valve. 2. mitral valve replacement with a size 31 st. mechanical valve. history of present illness: 28 yo m with pmh of ivdu, and aortic valve infective endocarditis admitted with infective endocarditis. he is transferred to the ccu for more monitoring in setting of worsened hypoxia, altered mental status and intermittent hypotension/bradycardia thought to be vagal in nature. . he was admitted here on after a 3 day stay at an osh. the day prior to that he presented to his pcp and found to have a 7 point hct drop 31--->24 and was referred to an osh ed. there, he has no elevation if wbc but had a 7% bandemia and blood cultures grew out strep. he was positive for cocain as well. after his blood cultures turned positive, he was transferred here for further care as there had been plan for valve replacement with dr. . . of note, his last episode of infective endocarditis was in the fall of and was treated with 3 months of iv antibiotics (unknown type). he had previously been on iv abx (unclear which kind for 3 months . since admission here, he has been doing well and had been treated with ceftriaxone and gentamycin. id has been following. blood cultures here have been negative. . he has been continued on his cardiac medications and received diuresis for fluid overload with lasix thought to be from his severe mr. repeat echo here showed 4+ mr, 4+ ai, ef 65% with 1cm vegetations on both the aoritic and mitral valves. there was also a likely vegetation attached to the left atrial wall in the region of the warfarin ridge. finally, the aortic root appeared thickened concerning for an abscess/phlegmon. . ct surgery was consulted given wide open mv and av on echo. though there is ct surgery note from this admission, per intern notes, recommendation was antibiotics, out pt drug rehab and goal of being drug free for 6 months prior to consideration for valve replacement. . he had been doing well since admission until last night at 10pm when he became anxious, reported chest pain. also had 2 episodes of bradycardia to high 30's which resolved without intervention and tele showed ? junctional rhythm. ekg showed twi in the precordial leads. the overnight team spoke with the cardiology fellow who felt that this was unlikely to be heart block as it resolved with no intervention. felt to be vagal and likely related to anxiety and he received ativan 1mg iv and he felt better. cardiac enzymes were sent and trop was 0.37 and ck/mb were normal. felt to likely be a coronary septic emboli and systemic anticoagulation is not favored given high risk of cns emboli and converstion to hemorrhage. ct head was negative though mri was recommended for complete rule out of emboli. . at 6am this morning, he triggered for tachypnia, hypoxia to mid 80's on room air. he noted to be diaphoretic and with chest pain. see trigger note for full details. he was again bradycardic, with bp's in the 100's, hypoxia to mid 80's on room air which reoslved to 2l nc. ekg showed deeper twi in precordial leads and twi in inferior leads. repeat trop down trended to 0.32 and ck/mb normal. cr increased to 1.6 and na down to 130. lactate was 3. there was concern that he had friends visiting the evening before and that he could have used an illicit drug. a room search was done and suboxone/naloxone combo pills were found. pill count showed an appropriate number of pills. urine and serum tox were negative. cardiac surgery consulted for urgent surgical correction. past medical history: aortic and mitral valve endocarditis s/p aortic and mitral valve replacement past medical history: viridin streptococcal endocarditis picc line infection - stenotrophomonas/enterobacter cloacae anxiety depression asthma surgery for pilonidal cyst s/p hernia repair social history: -tobacco: 1 ppd -etoh: denies -illicit drugs: denies, but cocaine postive at osh family history: father died at age 57 of an abdominal aortic aneurysm (heavy smoker). mother had cancer with a colectomy, gf died of asbestos physical exam: vs: tc 99.2 bp 96/53 hr 65 rr 18 100% ra general: diaphoretic male in nad. oriented x3. mood, affect appropriate. heent: eyebrown ring above left eyebrow. no evidence of focal hemmorage. sclera anicteric. perrl, eomi. conjunctiva were pink neck: supple without jvd cardiac: soft systolic murmur best heart at the mitral position, lungs: ctab abdomen: soft, ntnd. no hsm or tenderness extremities: 2+ lower extremity edema, non-pitting. left toe between digits 4 and 5 is torn with scab formation. skin: multiple tattos, but no signs of osler's nodes or lesions. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: 11:44pm blood wbc-13.0* rbc-3.77* hgb-9.6* hct-30.1* mcv-80* mch-25.5* mchc-31.9 rdw-18.0* plt ct-460* 11:44pm blood neuts-83.2* lymphs-9.2* monos-3.5 eos-3.1 baso-0.9 11:44pm blood pt-14.9* ptt-22.9 inr(pt)-1.3* 11:44pm blood glucose-129* urean-26* creat-1.5* na-130* k-4.1 cl-90* hco3-28 angap-16 05:49am blood alt-16 ast-24 ld(ldh)-208 alkphos-112 totbili-0.5 dirbili-0.3 indbili-0.2 11:44pm blood calcium-8.4 phos-5.0* mg-2.2 05:49am blood caltibc-268 hapto-309* ferritn-282 trf-206 05:49am blood crp-50.9* 11:45pm blood hiv ab-negative . echo : the left atrium is dilated. left ventricular wall thicknesses are normal. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets are mildly thickened with probable vegetation (~1cm diameter). the aortic root is irregularly thickened consistent with aortic phelgmon/abscess. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened with large perforation of the anterior leaflet. there is a large (~1.7 cm) vegetation on the mitral valve attached to the anterior leaflet in the region of the perforation. severe (4+) mitral regurgitation is seen. there is a moderate sized vegetation (~1.2 cm) attached to the left atrial wall in the region of the warfarin ridge. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is a very small pericardial effusion. in addition to the above vegetations, at least one additional vegetation (~0.6 cm diameter) is noted attached to the anterior mitral valve leaflet. compared with the prior report (images unavailable) of , findings are similar. the mitral valve vegetation appears slightly larger. tee conclusions prebypass no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. there is a small vegetation seen on the coumadin ridge. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is mildly depressed (lvef=45-50%). the right ventricular cavity is dilated with mild global free wall hypokinesis. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is a moderate-sized vegetation on the aortic valve. no aortic valve abscess is seen. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is partial anterior mitral leaflet flail. there is a moderate-sized vegetation on the mitral valve. severe (4+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is a small pericardial effusion. post bypass patient is in sinus rhythm and receiving an infusion of norepinephrine, vasopressin and milrinone. lvef= 40%. mechanical valve seen in the aortic position. it appears well seated and the lealfets move well. peak gradient across the aortic valve is 26 mm hg and the mean gradient is 13 mm hg. washing jets typical for this type of valve are seen. mechanical valve seen in the mitral posiiton. it appears well seated and the leaflets move well. the mean gradient across the mitral valve is 3 mm hg and the peak gradient is 5 mm hg. washing jets typical for this type of valve are also seen. trivial tricuspid regurgitation seen. aorta is intact post decannulation. brief hospital course: medicine course: 28 yo m with hemodynamically significant strep endocarditis in setting of likely transferred to ccu after decompensation with worsening heart failure, hypoxia, chest pain with ekg changes and troponin leak concerning for coronary emboli now s/p temporary pacer placement with plan for surgical intervention on . # bradycardia: on patient with episodes of intermittent symptomatic bradycardia to high 30 to low 40's. at that time tele with wide complex rhythm, poor baseline thus difficult to assess for p waves though appears to have some p waves on strip, appear to be non-conducting at an atrial rate of ~60 and a ventricular rate of ~40 consistent with intermittent heart block in setting of endocarditis/aortic wall abscess. patient was subsequently hemodynamically stable with temporary pacer in place. transfered to or for surgical treatment of his endocarditis . # hypoxia: likely decompensation in setting of wide open mv and av as result of infective endocarditis. clinically volume up. # streptococcus infective endocarditis: has vegetations on mv, av and . high concern for emboli given increase in trop, change in mental status though ct was negative. clinically has decompensated in spite of maximum medical therapy with appropriate antibiotics, treatment for heart failure. after extensive discussion plan to forge head with surgical intervention. # chest pain: occurs with his heart block likely precipitating cardiac ischemia. ekg with worsening twi initially in precordial leads and now in inferior leads as well. trop bump peak at 0.37, down to 0.32. per literature review, 40% of patients with ie have troponin leak. also concern for coronary emboli though ischemic from chb most likely. no role for systemic anticoagulation or cath in this setting. - temporary pacer in place. # acute renal failure: new in last 24 hours, likely in setting of worsening heart failure and poor forward flow. in setting of aggressive diuresis creatinine stable but elevated at 1.7 with adequate uop. # elevated lactate: likely to poor forward flow and likely peripheral ischemia . # drug dependance and abuse: cocaine positive at osh though patient denied. post-op course: the patient was brought to the operating room on where the patient underwent avr (23mm st. mechanical), mvr (31mm st. mechanical) with dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support by pod 2. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. coumadin was initiated for mechanical valves, with a heparin bridge. initial gram stain from or tissue grew gram negative rods. id continued to follow for antibiotic management. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod #7 he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to rehab in good condition with appropriate follow up instructions. medications on admission: buprenorphine-nalaxone 8 mg-2mg sublingually klonoprin 0.25 mg daily furosemide 80 mg daily lisinopril 10 mg daily potassium 20 meq daily discharge medications: 1. metoprolol tartrate 25 mg sig: one (1) po bid (2 times a day). 2. potassium chloride 10 meq extended release sig: two (2) extended release po q12h (every 12 hours). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ranitidine hcl 150 mg sig: one (1) po bid (2 times a day). 5. aspirin 81 mg , delayed release (e.c.) sig: one (1) , delayed release (e.c.) po daily (daily). 6. warfarin 1 mg sig: md daily (daily): inr goal=2.5-3.5 for mechanical avr/mvr . 7. acetaminophen 325 mg sig: two (2) po q4h (every 4 hours) as needed for pain/fever. 8. oxycodone-acetaminophen 5-325 mg sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 9. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 10. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 11. benzocaine 20 % paste sig: one (1) appl mucous membrane qid (4 times a day) as needed for oral sores. 12. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours): start date: stop date: (4 weeks as of surgery) . 13. gentamicin 40 mg/ml solution sig: 4.5 injection q24h (every 24 hours): start date: stop date: (2 weeks as of surgery) . 14. sodium chloride 0.9 % 0.9 % syringe sig: ten (10) ml injection once a day as needed for line flush: & prn. 15. warfarin 2 mg sig: one (1) po once for 1 doses: administer at 4pm . 16. furosemide 10 mg/ml solution sig: four (4) injection (2 times a day). discharge disposition: extended care facility: - discharge diagnosis: aortic and mitral valve endocarditis s/p aortic and mitral valve replacement past medical history: viridin streptococcal endocarditis picc line infection - stenotrophomonas/enterobacter cloacae anxiety depression asthma surgery for pilonidal cyst s/p hernia repair discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage edema- 2+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. date/time: 1:45 cardiologist: dr. at 2:35pm , md phone: date/time: 10:30 please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication: mechanical aortic and mitral valves goal inr 2.5-3.5 first draw then please do inr checks monday, wednesday, and friday for 2 weeks then decrease as directed by md *****antibiotic regimen and projected duration: and dose: ceftriaxone 2gmq24h start date: stop date: (4 weeks as of surgery) gentamicin 180mg iv q24 start date: stop date: (2 weeks as of surgery) required laboratory monitoring: lab tests: cbcdiff, bun, crea, lfts, vanco trough, gent trough, esr, crp frequency: qweekly all laboratory results should be faxed to infectious disease r.ns. at ( follow up appointments scheduled: 10:30a id,, lm , basement id west (sb) all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. at ( md procedure: extracorporeal circulation auxiliary to open heart surgery open and other replacement of aortic valve arterial catheterization open and other replacement of mitral valve other conversion of cardiac rhythm diagnoses: anemia of other chronic disease mitral valve disorders congestive heart failure, unspecified acute kidney failure, unspecified hyposmolality and/or hyponatremia asthma, unspecified type, unspecified aortic valve disorders other chronic pulmonary heart diseases dysthymic disorder other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure atrioventricular block, complete bacteremia acute and subacute bacterial endocarditis other postprocedural status carrier or suspected carrier of methicillin resistant staphylococcus aureus acute systolic heart failure streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus other and unspecified infection due to central venous catheter pilonidal cyst without mention of abscess other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms family history of malignant neoplasm of gastrointestinal tract cocaine dependence, unspecified 

Answer: The patient is high likely exposed to