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: ranitidine attending: chief complaint: tachycardia, chest pain major surgical or invasive procedure: right heart catheterization temporary dialysis catheter x2 ir tunneled hd catheter picc placement history of present illness: icu hpi: 69yom with h/o dm, cad s/p cabg, admission from osh for hyperkalemia and respiratory distress. he was admitted from his pcp's office to an osh for evaluation of new pan-cytopenia 2.1>28%<83, acute renal failure and symptoms of fatigue and weakness. he developed worsening oliguric renal failure and new heart failure and was tranferred to on for further workup of renal dysfunction and new pancytopenia. since transfer to it was thought that he was suffering renal failure from atn in setting of some combination of poor po intake, hypotension on bp meds and contrast load at osh. a temporary hd catheter was placed and he began dialysis. . he has also been evaluated by the hematology service and bone marrow suppression thought likely due to suppression in setting of acute illness but also pending ebv, cmv, parvovirus, spep. upep negative for monoclonal spike. hepatitis serologies negative. there was a plan for bone marrow bx. . of note, his blood cultures have grown out ampicillin sensitive enterococci, and he had a tte just yesterday showing a large aortic valve vegetation. he was switched to ampicillin yesterday. . he's also had a fair amount of anginal-type chest pain and was evaluated by cardiology. he's had anginal chest pain for quite a while, maybe x2 / month, worsened with exertion and relieved with rest. denies palpitations. tonight, his hr increased to the 140s, in sinus, with lateral st depressions, which resolved with rate control using metoprolol 5mg iv. this appears to have been going on nightly for several nights according to the floor night resident. he has been getting nitro paste and nebs. . vs on transfer to the floor were: 108/75, 88, 32, 95/4l. on exam on the floor, he has cardiac wheeze. abg showed 7.4 / 35 / 77 on 4l. he looks well, but has some minor anterior chest pain. . ros: as above, otherwise negative for sob, n/v/abd pain/diarrhea, palpitations, dizziness. . of note, pt was admitted with enterococcal uti, finished 7d course ampicillin past medical history: pmh: radiation cystitis s/p 60 hyperbaric oxygen treatments in , clot irrigation , transfusions, silver nitrate irrigation, forumlin prostate cancer s/p rrp, xrt colon cancer stage iii s/p colectomy/postop folfox cad s/p cabg/ three stents carotid stenosis angina requiring nitroglycerin htn dm ii gerd psh: cabg, radical prostatectomy, cholecystectomy, appendectomy, sigmoid colectomy, cystoscopy, clot evacuation, cystoscopy, formulin instillation pmh: adenocarcinoma of the rectosigmoid hypertension coronary artery disease prostate cancer diabetes mellitus type 2 psh: s/p cabg x4 s/p prostatectomy s/p appendectomy s/p cholecystectomy s/p ear, tonsil and adenoid surgery s/p femoral rodding s/p back surgery social history: retired estimator for an environmental company. lives with wife. 4 healthy children and 4 grandchildren. quit smoking in , but previously smoked ppd (~120 pack years). previously drank ~ case of beer daily, now sober for many years. denies illicit drug use. family history: - the patient does not know his biological parents physical exam: on admission: icu physical: 97.4 p83 107/50 20 98% 2l nc thin pleasant gentleman in no distress, appears stable, alert/conversant/attentive eomi, no scleral icterus jv pulsations noted at the earlobe with +hjr soft expiratory wheezes with r < l breath sounds, good air movement rrr with frequent ectopy and systolic murmur heard at busb, less at apex. midline cabg scar noted. soft nt nd abdomen, benign notable pitting edema to mid shin, without chronic venous stasis changes noted, extremities are warm well perfused cn 2-12 intact, no focal neuro deficits noted medicine floor physical: vitals: t: 98.2 bp: 124/56 p: 81 r: 18 o2: 93% 2l general: alert, oriented, tachypneic on moving in bed for exam, can speak in full sentences heent: sclera anicteric, mmm, oropharynx clear, hard of hearing neck: supple, jvp not elevated, no lad lungs: right lower lobe crackles, decreased breath sounds to mid back b/l, using accessory muscles to breathe (abdomen) cv: distant heart sounds, regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops, midline sternotomy scar abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, midline scar just below umbilicus ext: warm, well perfused, 1+ pulses, no clubbing neuro: a+ox3, difficulties with attention: saying the days of the week backwards, but can count backwards pertinent results: admission labs: 07:00pm glucose-84 urea n-122* creat-6.6*# sodium-131* potassium-5.2* chloride-99 total co2-21* anion gap-16 07:00pm alt(sgpt)-17 ast(sgot)-24 ld(ldh)-232 alk phos-114 tot bili-0.6 07:00pm albumin-2.3* calcium-7.5* phosphate-7.9*# magnesium-2.2 07:00pm haptoglob-121 07:00pm wbc-2.8* rbc-3.27* hgb-9.3* hct-27.9* mcv-86# mch-28.5# mchc-33.3 rdw-16.5* 07:00pm neuts-73* bands-7* lymphs-10* monos-6 eos-2 basos-0 atyps-2* metas-0 myelos-0 07:00pm hypochrom-1+ anisocyt-2+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-normal spherocyt-1+ bite-occasional 07:00pm plt smr-very low plt count-62*# 07:00pm pt-14.3* ptt-33.8 inr(pt)-1.2* 07:00pm ret aut-2.5 discharge labs: micro: 1:32 pm blood culture source: line-picc. **final report ** blood culture, routine (final ): enterococcus faecalis. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. daptomycin = 1.5 mcg/ml, sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s daptomycin------------ s penicillin g---------- 4 s vancomycin------------ 1 s anaerobic bottle gram stain (final ): gram positive cocci in pairs and chains. reported to and read back by dr. () @ 8:43am . aerobic bottle gram stain (final ): gram positive cocci in pairs and chains. time taken not noted log-in date/time: 4:12 pm blood (ebv) specimen taken from chem# g. **final report ** - virus vca-igg ab (final ): positive by eia. - virus ebna igg ab (final ): positive by eia. - virus vca-igm ab (final ): positive >=1:10 by ifa. interpretation: uninterpretable ebv pattern. in most populations, 90% of adults have been infected at sometime with ebv and will have measurable vca igg and ebna antibodies. antibodies to ebna develop 6-8 weeks after primary infection and remain present for life. presence of vca igm antibodies indicates recent primary infection. studies: renal u/s : impression: normal sized kidneys, with mildly increased cortical echogenicity suggestive of renal disease. interval resolution of previoulsy seen bilateral hydronephrosis. tte : conclusions the left atrium is dilated. the left ventricular cavity size is top normal/borderline dilated. there is mild to moderate regional left ventricular systolic dysfunction with anteroseptal/anterior hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets are moderately thickened. there is a large vegetation on the aortic valve. there is a minimally increased gradient consistent with minimal aortic valve stenosis. eccentric mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. at least moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. tte : conclusions the interventricular septum and apex of the left ventricle are hypokinetic. right ventricular chamber size is normal with depressed free wall contractility. the aortic valve leaflets are moderately thickened. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. vegetations are present on all three aortic valve cusps. no obvious abscess seen but cannot be axcluded on the basis of this study. compared with the findings of the prior study (images reviewed) of , the findings are similar. ct chest : impression: 1. moderate bilateral pleural effusions. adjacent consolidation is most likely atelectasis, but infection cannot be excluded. 2. small right middle lobe consolidation is also most likely atelectasis, less likely infection. 3. mild pulmonary edema. 4. mild centrilobular emphysema. 5. increased number and top normal size of mediastinal and retrotracheal lymph nodes are likely reactive. 6. mild splenomegaly. ct head w/o : impression: no acute intracranial process. ct has poor sensitive for small embolic infarcts. an mr may be obtained for further evaluation if the clinical concern persists. tte : conclusions focused views to assess size of known aortic valve vegetation and degree of aortic regurgitation. the aortic valve leaflets are moderately thickened. the larger of the aortic valve vegetations previously seen on complete studies dated and is now characterized by a wider base (more linear and mobile on the prior studies). the degree of aortic regurgitation is still in the mild-moderate range. an abscess was not visualized but cannot be excluded on the base of this study. tte : focused study. there is mild regional left ventricular systolic dysfunction with focal hypokinesis to akinesis of the mid to distal anterior septum, anterior wall, and apex. the right ventricular cavity is dilated and mildly hypokinetic. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. there is a moderate-sized vegetation on the aortic valve. moderate (2+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. compared with the prior study (images reviewed) of /201, the vegetation size appears similar but the severity of aortic regurgitation is slightly increased. brief hospital course: mr. is a 69year old m with cad s/p cabg, who presented with chest pain, tachycardia, found to have high grade enterococcal bacteremia with native aortic valve vegetation. he was transfered to the icu for hypoxia and unstable angina. he was placed on ampicillin for enterococcal endocarditis. cardiology followed the pt and felt that his chest pain was heart failure and volume overload. his hospitalization was complicated by acute renal failure thought to be atn, requiring dialysis. ct surgery was consulted, but given only mild-moderate ar, no surgery was recommended. # enterococcal endocarditis: pt has a history of enterococcal uti in setting of past prostatectomy/radiation and radiation cystitis with a recent admission in for enterococcal uti. he was started on ampicillin with surveillance blood cultures, and id following. tte showed a large aortic valve vegetation, with ef 40-45%. his course was complicated by new heart failure. cardiology followed the pt, and attributed his chest pain to heart failure and volume overload. he had a pa cathether placed which suggested more of a septic than cardiogenic picture of hypotension. as discussed below, he had dialsysis for fluid removal. cardiothoracic surgery was consulted, and recommended no intervention. tee was considered, but given pt was hypotensive, this was not pursued. repeat tte on showed no change, with no severe ai. tte was again repeated on , and showed mildly increased base of vegetation, but continued mild-moderate ar. per ct surgery, no intervention given ar not severe. per id, gentamicin was added, dosed after dialysis. followed troughs prior to each dialysis session, with goal =<1.0. repeat echo done that showed a stable vegetation with slight increase in aortic regurgitation. cardiology and cardiac surgery were notified, as patient was clinically improving there were no changes to the plan. last positive blood culture was . all following cultures were negative at the time of discharge and the patient remained afebrile. he should be continued on ampicillin and gentamicin at least until when he follows up in clinic, with further course to be decided by them. he should continue to have a chem 7, cbc and lft panel done weekly, with results faxed to dr. in the infectious disease department at . # acute renal failure: secondary to atn with no evidence of abscess or septic emboli from imaging at osh and no evidence of abscess on u/s here. atn thought to be secondary to poor po intake, volume contraction/hypotension. renal was consulted, and given volume overload, pt had temporary line placed for hd. he was started on nephrocaps and sevelamer. he had a line holiday given bacteremia as discussed above, on a tunneled hd line was placed. he had dialyis with intervening hemofiltration to remove fluid as quickly as possible. # acute systolic chf: thought to be new onset heart failure and volume overload as discussed above. ecg demonstrated st depressions in precordial and lateral leads. cardiac enzymes were trended and remained stable. metoprolol was increased in the icu for improved rate control. cardiology followed the pt and did not feel anything other than supportive treatment was appropriate. he was started on imdur 30mg daily, with sl nitroglycerin on a prn basis. he should follow-up with his cardiologist as an outpatient to decide whether intervention for his angina would be beneficial once his symptoms have stabilized. fluid overload, with components of acute pulmonary edema and chronic lung disease. the patient remains tachypneic with even small amounts of exertion. he improves with ipratropium and albuterol nebulizers. when he continues to be dypsneic, sl nitroglycerin can be used, especially in the setting of anginal symptoms. other times, especially if he is anxious, 1mg of iv morphine can remove some of the work of breathing and make him more comfortable. as he continues to have fluid removed with dialysis, his breathing has been steadily improving. # pancytopenia: unclear etiology. hematology was consulted, and workup was initiated on the medicine floors with hiv negative, upep negative. spep resulted as slightly abnormal, and repeat spep continued to show abnormalities. however, per heme, this was of unclear significance. ebv serologies showed positive igg and igm, of unclear significance. parvovirus showed positive igg, negative igm. they felt this was most likely endocarditis/sepsis. # delirium: pt became confused as to the date, and appeared delirious during his micu course. a ct head showed no acute process. serial neurologic exams remained nonfocal. this was attributed to toxic metabolic encephalopathy given hd had been held, pain, and sepsis. he was started on mirtazapine & seroquel and moved from the icu to the general medicine floor with drastic improvement in his symptoms. at the time of discharge, he was alert and oriented x3, able to do months of the year backwards, and able to remember historical details. #. type 2 dm: at home, patient on glargine 8 units qhs and a humalog sliding scale. here, he was on a humalog sliding scale alone. as his health and appetite improve, he should be transferred back to his home regimen. patient was transferred to an ltac at medications on admission: home medications: - imdur 90 mg 1xd - humalog 8 units prn - docusate 100 mg prn - miralax prn - nitroglycerin sl prn - multivitamin 2 tabs 1xd - ranexa 1000 mg - crestor 10 mg 1xd - lopressor 25 mg - tylenol prn - calcium carbonate 500 mg - percocet 5 1 tab q4h prn - zofran 4 mg po prn . meds on transfer to micu (): tylenol prn ampicillin 2 g iv q12h since at 1450 docusate heparin 5000 sc tid insulin sliding scale ipratropium neb isosorbide mononitrate er 60mg daily metoprolol tartrate 12.5mg nitroglycerin sl 0.3 prn cp nephrocaps 1 daily nitroglycerin ointment 2% senna prn sevelamer carbonate 1600mg po tid with meals . meds on transfer from micu to floor (): acetaminophen 325-650mg po q6h:prn pain ampicillin 2g iv q12h aspirin 325mg po daily atorvastatin 80mg po daily cepacol (menthol) 1 loz prn sore throat docusate sodium 100mg po bid dextrose 50% 12.5g iv prn hypoglycemia gentamicin 60mg iv qhd glucagon 1mg im q15min: prn hypoglycemia heparin 5000units sc tid heparin dwell (1000units/ml) -8000unit dwell prn hd line ipratropium bromide neb q6h insulin sc sliding scale isosorbide mononitrate (er) 30mg po daily maalox/diphenhydramine/lidocaine 15-30ml po tid:prn pain metoprolol tartrate 25mg po qid morphine sulfate 1mg iv q4h:prn chest pain mirtazapine 7.5mg po hs nephrocaps 1 cap po daily nitroglycerin sl 0.3mg sl prn chest pain quetiapine fumarate 12.5mg po hs 6pm senna 1 tab :prn constipation xopenex neb sevelamer 1600mg po tid with meals discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po qid (4 times a day). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 3. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: repeat q5 minutes x3 or until relief of symptoms. 6. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 7. ampicillin 2 g iv q12h 8. gentamicin sulfate (pf) 60 mg/6 ml solution sig: sixty (60) mg intravenous qhd: measure trough prior to dialysis and give full dose if trough<1.0. 9. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 10. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 11. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours). 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours). 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q2h (every 2 hours) as needed for shortness of breath. 14. humalog 100 unit/ml solution sig: as directed units subcutaneous qachs: per sliding scale. 15. morphine 5 mg/ml solution sig: one (1) mg injection q4h (every 4 hours) as needed for dyspnea: to ease breathing for refractory dyspnea. hold for sedation. 16. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime): for appetite stimulation. 17. quetiapine 25 mg tablet sig: 0.5 tablet po hs (at bedtime): give at 6pm. 18. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day): continue until patient ambulatory. 19. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 21. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours). 22. heparin (porcine) 1,000 unit/ml solution sig: -8000 unit injection prn (as needed) as needed for dialysis: dwell to catheter volume. discharge disposition: extended care facility: tcu - discharge diagnosis: enterococcal bacteremia enterococcal native aortic valve endocarditis acute renal failure pancytopenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted for an infection in your blood causing injury to your heart, lungs, and bone marrow. this required you to stay in the intensive care unit for 2 weeks. your aortic heart valve became infected from the infection in your blood and you need a long course of antibiotics (ampicillin and gentamicin) to clear the infection, which were started while you were in the intensive care unit. pictures of your heart were taken to look at the infection of the valve. also, your kidneys were damaged because of low blood flow during the infection. your kidneys were no longer able to produce urine and you needed to have dialysis to remove fluid from your body. since your bone marrow was also injured you needed blood transfusions. . you were having difficulty breathing, which was from the fluid in your lungs. dialysis was used to remove the fluid and we gave you nebulizers, nitroglycerin, and morphine to help your breathing. you also had episodes of chest pain that were relieved with nitroglycerin and your ecg showed changes that were consistent with your known heart disease and the extra demand on your heart from the infection. . you are going to a long term acute care facility to help you regain strength and to continue to monitor your kidney function and heart valve infection. you will continue to get dialysis at the facility if your kidneys are still not working. . medications started while in the hospital include: ampicillin (antibiotic) gentamicin (antibiotic) morphine (breathing) albuterol (breathing) ipratropium (breathing) mirtazipine (appetite stimulant) quetiapine (to help with sleep - you should be able to stop when you leave the hospital) sevelamer (kidney) nephrocaps (kidney) . medications we stopped in the hospital: ranexa calcium carbonate percocet zofran . medication we changed while in the hospital: imdur was decreased (for blood pressure and chest pain) metoprolol was increased (for heartrate control) take atorvastatin instead of rosuvastatin for cholesterol . please go to your scheduled appointments. followup instructions: name: , : internal medicine location: healthcare - address: , , phone: **please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge** you have an appointment with infectious disease on at 11:30am because of the infection on your heart valve. the provider will be , md, phone number . department: hematology/oncology when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage name: , : cardiology location: healthcare - address: 15 brothers way,, , phone: appointment: wednesday at 11am procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis right heart cardiac catheterization diagnoses: hyperpotassemia thrombocytopenia, unspecified esophageal reflux intermediate coronary syndrome acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified toxic encephalopathy severe sepsis chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation personal history of malignant neoplasm of prostate coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status percutaneous transluminal coronary angioplasty status occlusion and stenosis of carotid artery without mention of cerebral infarction chronic kidney disease, stage iii (moderate) acute respiratory failure long-term (current) use of insulin personal history of malignant neoplasm of large intestine other constipation acute and subacute bacterial endocarditis other specified peripheral vascular diseases acute systolic heart failure streptococcal septicemia delirium due to conditions classified elsewhere personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health background diabetic retinopathy acute edema of lung, unspecified nutritional marasmus arthropathy, unspecified, site unspecified diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled 

Answer: The patient is high likely exposed to