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: ambien attending: chief complaint: chest pain, "heartburn" major surgical or invasive procedure: cardiac catheterizaation (without intervention) colonoscopy (with polypectomy) flexible sigmoidoscopy right anterior septum cautery for epistaxis flexible sigmoidoscopy diverting colostomy, hartmann's pouch and placement of presacral drain and drainage of a submucosal hematoma from the rectum import major surgical or invasive procedure history of present illness: mr. is a 74 yo m w/ h/o mvr/avr rheumtic heart disease, a fib, chf, s/p biv pacer, htn, hyperlipidemia, copd, ckd baseline cr 1.6, obesity who presents with chest pain which started . it was described as epigastric and associated with nausea, vomitting, diaphoresis and "sour feeling". it improved with maalox in ed. he had 2 sets of cardiac enzymes which were negative. his nuclear stress did show a "moderate fixed defect of inferior wall, moderated reversible defect of inferolateral wall, new partially reversible defect of anterior wall. a cardiac catherization was done on . on arrival to the floor, pt has no compliants. he does state he has had increasing doe for the last 10 days or so which his inhalers initially helped. pt also c/o mild ankle edema just during the day today. . on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . past medical history: 1. cardiac risk factors: dyslipidemia, hypertension 2. cardiac history: # mechanical mvr/avr () rheumatic fever # atrial fibrillation s/p av node ablation, biventricular pacer () on anticoagulation # biventricular pacer . 3. other past medical history: # copd # asthma # gerd # osteoarthritis # bilateral total knee replacements oa # gout # hypothyroidism amiodarone # chronic kidney disease stage ii, baseline cr 1.6 # anemia # melanoma # obesity # etoh use # insomnia # hemorrhoids # h/o cellulitis # h/o mrsa pna # osteopenia # # s/p cholecystectomy # s/p appendectomy social history: # personal: lives with wife and 2 step sons aged 45 and 34. pt states he could walk 3mi at a time recently but hasn't been able to do this in several mo. can walk up 3 flts at a time. # professional: retired construction worker. # tobacco: 1ppd x 15y, quit . # alcohol: former binge alcohol abuse x30y (hard liquor), quit mid . last drank 3 mo ago- 3 drinks at that time # recreational drugs: experimental mescaline in youth. family history: # mother d 85: asthma # father d 99 : pad, htn # siblings (5b, 2s): htn, unknown, rheumatic fever physical exam: vs: t=99.2 bp= 104/68 hr= 64 rr=18 o2 sat= 97% on ra general: obese m in nad. oriented x3. mood, affect appropriate. : ncat. sclera anicteric. neck: supple with jvp of 8 cm. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd.obese extremities: trace pedal edema bilat, wwp, trace tp bilat. skin: + hyperpigementation on calves c/w venous stasis physical examination upon discharge: vital signs: bp=108/54, hr=61. resp. rate 18, t=97.5, oxygen saturation 98% ra general: nad, sitting in chair, alert and oriented cv: ns1, s2, -s3, -s4, no murmurs lungs: clear abdomen: soft, non-tender,ostomy with light brown watery stool, wet to dry dressing to lower aspect of wound, wound margins erythematous, no exudate extremities: +1 edema lower ext., mild erythema lower aspect of legs bil., + dp bil pertinent results: admission labs: 03:45am blood wbc-11.1* rbc-4.23* hgb-12.5* hct-36.5* mcv-86 mch-29.4 mchc-34.1 rdw-17.2* plt ct-162 03:45am blood neuts-70 bands-2 lymphs-17* monos-7 eos-3 baso-1 atyps-0 metas-0 myelos-0 03:45am blood pt-31.1* ptt-32.7 inr(pt)-3.1* 03:45am blood glucose-112* urean-58* creat-1.7* na-135 k-4.5 cl-101 hco3-25 angap-14 05:40am blood calcium-8.7 phos-2.7 mg-2.6 03:45am blood alt-27 ast-38 alkphos-86 totbili-0.6 03:45am blood ctropnt-<0.01 09:43am blood ctropnt-less than labs upon transfer to micu: 06:30am blood wbc-28.0* rbc-3.08* hgb-9.3* hct-27.7* mcv-90 mch-30.2 mchc-33.6 rdw-17.2* plt ct-231 09:05am blood neuts-87.1* lymphs-7.1* monos-4.6 eos-1.1 baso-0.2 06:30am blood pt-18.6* ptt-86.5* inr(pt)-1.7* 06:30am blood glucose-123* urean-49* creat-2.4*# na-132* k-5.1 cl-96 hco3-28 angap-13 06:30am blood calcium-8.4 phos-3.9 mg-3.0* ekg ventricular paced rhythm. the underlying rhythm is probably atrial fibrillation : kub impression: essentially unchanged air filled loops of large and small bowel, representing unchanged ileus cxr impression: no acute intrathoracic process. stress test/perfusion scan: : impression: uninterpretable ecg for ischemia. no anginal type symptoms reported. appropriate hemodynamic response to persantine. nuclear report filed separately impression: abnormal study. there is a moderate fixed defect of the inferior wall with associated hypokinesis, a moderate reversible defect of the inferolateral wall, and a new partially reversible defect of the anterior wall. new, moderate left ventricular enlargement. left ventricular ejection fraction 37% (previously 47%). cardiac cath comments: 1. selective coronary angiography of this co-dominant system demonstrated no angiographically apparent, flow-limiting coronary artery disease. the lmca was normal in apperence. the lad had mild lumenal irregularities with small caliber branch vessels. the lcx was a co-dominant vessel with minor irregularities. the rca had mild disease. final diagnosis: 1. non-obstructice coronary artery disease. egd impression: granularity in the antrum compatible with gastritis (biopsy) otherwise normal egd to third part of the duodenum colonoscopy impression: polyp at 15cm in the rectosigmoid junction (15cm) (polypectomy, endoclip) otherwise normal colonoscopy to cecum pathology from polypectomy 1. stomach, antrum, biopsy (a): focal superficial iron deposition in the lamina propria, consistent with iron pill gastropathy (confirmed on iron stain). 2. polyp, rectosigmoid, polypectomy (b-c): adenoma. flexible sigmoidoscopy impression: blood in the up to 30cm from the anal verge. there was no blood proximal to this. (endoclip) otherwise normal sigmoidoscopy to 30cm from anal verge flexible sigmoidoscopy impression: post-polypectomy site with friable mucosa but no stigmata of recent bleeding. (injection, endoclip) prior endoclipped site (clipped on ) appeared clean without any friable mucosa, stigmata or recent bleeding, or active bleeding. otherwise normal sigmoidoscopy to 20cm from the anal verge ct abdomen/pelvis w/o contrast impression: 1. high-density material within the rectum may represent stool, although blood cannot be excluded. clinical correlation with stool sample or physical exam recommended. 2. two fat containing midline abdominal wall hernias appear grossly uncomplicated by ct although minimal stranding may represent an element of strangulation. clinical correlation with point tenderness recommended. 3. distended bladder. abdomen (supine & erect) ng tube coiling in esophagus. multiple distended loops of bowel concerning for bowel obstruction or ileus echo: : suboptimal image quality.the left atrium is markedly dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is mildly depressed (lvef= 40-50 %). the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no masses or vegetations are seen on the aortic valve. a bileaflet mitral valve prosthesis is present. the mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no mass or vegetation is seen on the mitral valve. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , no definite change. if indicated, a tee would better assess for endocarditis : current lab work: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:30 8.4 2.56* 7.4* 22.7* 89 29.0 32.8 16.2* 404 differential neuts bands lymphs monos eos baso atyps metas myelos nrbc 05:40 80* 2 11* 6 0 0 0 1* 0 1* red cell morphology hypochr anisocy poiklo macrocy microcy polychr ovalocy tear dr 05:40 1+ normal normal normal normal normal basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 05:30 404 05:30 33.0* 33.9 3.3* lab use only 05:30 chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:30 91 28* 1.4* 131* 4.2 95* 27 13 using this patient's age, gender, and serum creatinine value of 1.0, estimated gfr = 73 if non african-american (ml/min/1.73 m2) estimated gfr = >75 if african-american (ml/min/1.73 m2) for comparison, mean gfr for age group 70+ is 75 (ml/min/1.73 m2) gfr<60 = chronic kidney disease, gfr<15 = kidney failure : impression: essentially unchanged air filled loops of large and small bowel, representing unchanged ileus. brief hospital course: mr. is a 74y/o gentleman with h/o mitral and aortic valve replacements rheumatic heart disease, a fib s/p ablation and biv pacer, systolic chf (ef 40%), htn, hld, copd, ckd baseline cr 1.6, obesity who presented with epigastric/chest pain and abnormal stress test. his cardiac cath showed no disease requiring intervention. due to his mechanic valves, he needs to be anticoagulated (inr 2.5-3.5), so while he was admitted and on a heparin drip for his cardiac cath, the decision was made to perform egd/colonoscopy to investigate a s.bovis blood culture from 1 year prior. colonoscopy showed 3cm polyp at rectosigmoid junction, which was removed (path negative for malignancy). he had a subsequent gi bleed requiring blood transfusions, 2 flexible sigmoidoscopies to place clips to the polypectomy site. his course was further complicated by leukocytosis/fever, hypotension, as well as ileus vs obstruction. cxr for ng tube placement suggested free air under the right diaphragm. surgery consult was called and he was transferred to the icu. he was taken to the operating room on for repair of his perforated simoid colon. his operative course was stable. he did receive blood during the procedure, but was extubated in the operating room and maintained stable hemodynamics. his post-operative pain was managed with dilaudid. he began sips and advanced to a clear diet. on he was transferred to the surgical floor. upon admission to the surgical floor, his vital signs have been stable. his coumadin was resumed at his preop dose and his inr is in the 2-2.5 range. he is tolerating a regular diet and his pain is well controlled. his stoma is slightly necrotic superficially and has some circumferial separation with a yellow wound bed and friable tissue. he has had a small amount of formed soft stool. the ostomy nurse has been following him on a regular basis and attempting to teach his wife ostomy care as mr. is unable to do it due to his large pannus. his abdominal wound became cellulitic on post op day 7 without any drainage and vancomycin was started without any improvement. after 2 days the lower pole of the incision was opened up and packed with minimal drainage. a vac dressing was eventually applied and his cellulitis resolved after the wound was opened. vancomycin was stopped on . he developed urinary retention on and had his foley catheter replaced. he will need another voiding trial as he becomes more ambulatory. mr. continues to expel some bloody drainage from his rectal hematoma and his hematocrit has been in the 23-25 range since . after a long complicated admission he will be discharged to a short term rehab so that he can increase his mobility, improve his endurance and gradually be proficient in his ostomy care. his abdominal vac dressing has been removed and replaced with a wet-dry dressing. he will need to have re-application of the vac dressing. of note, no rectal temperatures or rectal procedures . medications on admission: allopurinol - 300 mg daily ciclopirox - 0.77 % gel - apply to abdomen folds twice a day colchicine - 0.6 mg daily prn gout (last taken 2 days ago) enalapril maleate - 20 mg fluticasone - 50 mcg- sprays each nostril once a day fluticasone-salmeterol - 250-50 mcg- 1 puff furosemide - 80 mg daily ipratropium-albuterol - 0.5 mg-2.5 mg/3 ml - 1 neb qid prn sob ipratropium-albuterol 103 mcg (90 mcg)-18 mcg- 1-2 puffs qid prn levothyroxine - 88 mcg daiyl metoprolol succinate - 50 mg daily orphenadrine citrate - 100 mg prn back pain pantoprazole - 40 mg sildenafil - 50mg prn trazodone - 50 mg tablet - to 1 tab qhs prn warfarin 5 mg mon and fri, 7.5 mg all other days ferrous sulfate - 325 mg daily loratadine - 10 mg tablet - 1 tablet(s) by mouth once a day discharge medications: 1. warfarin 5 mg tablet sig: one (1) tablet po once a day: 1 tab on and friday, 1.5 tabs on all other days. 2. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 3. enalapril maleate 20 mg tablet sig: one (1) tablet po twice a day. 4. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 6. allopurinol 300 mg tablet sig: one (1) tablet po once a day. 7. colchicine 0.6 mg tablet sig: one (1) tablet po once a day as needed for gout. 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 9. ciclopirox 0.77 % gel sig: one (1) application to abdomen folds topical twice a day. 10. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 11. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 12. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for sob. 13. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) neb inhalation four times a day as needed for shortness of breath or wheezing. 14. loratadine 10 mg tablet sig: one (1) tablet po once a day. 15. orphenadrine citrate 100 mg tablet sustained release sig: one (1) tablet sustained release po twice a day as needed for back pain. 16. sildenafil 50 mg tablet sig: one (1) tablet po once as needed for sexual activity. 17. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 18. trazodone 50 mg tablet sig: to 1 tablet po at bedtime as needed for insomnia. 19. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for diarrhea. 20. sodium chloride 0.65 % aerosol, spray sig: three (3) spray nasal tid (3 times a day). 21. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 22. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation: hold for diarrhea. discharge disposition: extended care facility: - discharge diagnosis: chest pain/abnormal stress test diagnostic colonoscopy secondary to strep bovis bacteremia perforated sigmoid colon, submucosal hematoma. right anterior epistaxis wound infection acute blood loss anemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - needs assistance discharge instructions: you came to the er because of abdominal/chest discomfort and you were admitted to the cardiology floor because of an abnormal stress test. you underwent cardiac catheterization and were found to have no heart vessel blockages that needed to be opened. you have been pain free since admission. your pain may have been related to acid reflux. . in addition, you have a history of strep bovis (a bacteria) and as a result you required a colonoscopy. since you were on a heparin drip anyway, you had this done while you were here. after the procedure, you had problems with severe lower abdominal pain, bleeding from your rectum and fever. you went to the operating room on where you were found to have a perforated sigmoid colon. you underwent a colostomy and drainage of a rectal hematoma. you are now preparing for discharge with the following instructions: please call your doctor or nurse practitioner or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you may see blood or dark/black material from your rectum over the next few weeks. that is from the rectal hematoma which is liquifying and draining. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain in not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. followup instructions: call the acute care clinic at for a follow up appointment in 2 weeks. call the clinic at for a follow up appointment in weeks. provider: , : date/time: 10:00 provider: , md phone: date/time: 9:40 provider: phone: date/time: 9:00 procedure: coronary arteriography using two catheters left heart cardiac catheterization colostomy, not otherwise specified esophagogastroduodenoscopy [egd] with closed biopsy endoscopic destruction of other lesion or tissue of large intestine endoscopic destruction of other lesion or tissue of large intestine repair of other hernia of anterior abdominal wall [endoscopic] polypectomy of rectum control of epistaxis by cauterization (and packing) peripheral nerve injection, not otherwise specified proctotomy diagnoses: esophageal reflux cellulitis and abscess of trunk congestive heart failure, unspecified acute posthemorrhagic anemia acute kidney failure, unspecified hyposmolality and/or hyponatremia gout, unspecified atrial fibrillation hematoma complicating a procedure accidental puncture or laceration during a procedure, not elsewhere classified heart valve replaced by other means hemorrhage complicating a procedure other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation morbid obesity chronic systolic heart failure osteoarthrosis, unspecified whether generalized or localized, site unspecified paralytic ileus retention of urine, unspecified accidents occurring in residential institution unspecified gastritis and gastroduodenitis, without mention of hemorrhage epistaxis hypertensive chronic kidney disease, benign, with chronic kidney disease stage i through stage iv, or unspecified benign neoplasm of rectum and anal canal ventral, unspecified, hernia without mention of obstruction or gangrene chronic kidney disease, stage ii (mild) cardiac rhythm regulators causing adverse effects in therapeutic use accidental cut, puncture, perforation or hemorrhage during endoscopic examination body mass index 40.0-44.9, adult infection of colostomy or enterostomy other iatrogenic hypothyroidism 

Answer: The patient is high likely exposed to