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 a 75 year old white male patient with a history of rheumatic heart disease and a six month history of increasing dyspnea on exertion. he has no associated chest pain or syncope. transthoracic echocardiogram revealed a dilated left atrium as well as severe aortic stenosis, moderate mitral stenosis, mild mitral regurgitation, mild aortic insufficiency and 3+ tricuspid regurgitation. cardiac catheterization showed a preserved left ventricular function as well as normal coronary arteries. the patient is referred for aortic valve and mitral valve replacement. past medical history: 1. cerebrovascular accident times two in , and , with no residual. 2. heavy smoking history, 120 pack years, quit approximately one month prior to admission. 3. chronic atrial fibrillation. 4. status post colon resection in . 5. status post bilateral cataract removal. social history: the patient denies alcohol intake. medications on admission: 1. digoxin 0.25 mg p.o. once daily. 2. coumadin 5 mg p.o. once daily. 3. lopressor 25 mg p.o. twice a day. 4. flovent and combivent inhalers twice a day. 5. lipitor 10 mg p.o. once daily. allergies: the patient states no known drug allergies. hospital course: the patient was admitted to the hospital on the day of surgery. he was taken to the operating room on , where he underwent aortic valve replacement which was a #23 tissue valve as well as a mitral valve replacement with a #27 tissue valve. postoperatively, the patient was transported from the operating room to the cardiac surgery recovery room on milrinone, epinephrine intravenous drip, eventually added levophed, propofol, insulin and amiodarone drips. the patient required a fair amount of intravenous fluids initially because of hypotension and he was av paced upon arrival from the operating room. the morning of postoperative day number one the patient continued overnight with some hemodynamic instability and significant hypotension. because of this, he underwent a transesophageal echocardiogram which revealed some right ventricular free wall hypokinesis as well as well seated and functioning valves. he also underwent a bronchoscopy at that time which showed severe tracheomalacia and increased secretions. the following day the patient remains on full ventilator support, remains on amiodarone, epinephrine, milrinone and vasopressin intravenous drip. he remained sedated to tolerate his ventilator support as well as due to some hemodynamic instability. on , the patient was begun with diuresis as it looked at that time like he was going to require longer term ventilator support and was started on tube feedings. also on , the patient received a consultation by the hematology service due to thrombocytopenia. their recommendation was to discontinue possible drugs which could contribute to thrombocytopenia and his heparin induced thrombocytopenic screen ultimately came back negative. the following day postoperative day four the levophed was discontinued although the patient remained sedated to tolerate full ventilator support. he was also on epinephrine and vasopressin at that time and sedated with fentanyl and versed drips. the following day the patient underwent another bronchoscopy due to continued secretions and his tracheomalacia was looking to be improved. some secretions were clean out during the bronchoscopy and his chest tubes were discontinued. the following day the patient remained on epinephrine, vasopressin drip although decreasing doses of both. postoperative day seven, the patient was noted to have high tube feed residuals and reglan was initiated. the patient was ultimately ramped up to goal on tube feeds. thrombocytopenia was noted to have been resolving at that time he underwent another bronchoscopy due to increased secretions and was cleaned out adequately. by postoperative day nine, the patient was noted to be waking up, more responsive, able to tolerate wakefulness on the ventilator, was noted to have increased abdominal tenderness as well as marginally elevated temperature and white blood cell count as well as elevated liver function tests. ultrasound at that time of his abdomen revealed a dilated gallbladder. a general surgery consultation was obtained by dr. , who recommended cholecystostomy tubes to be placed. the following day, , the patient was taken to the interventional radiology department where he underwent placement of a cholecystostomy tube. it was the general surgery consult services recommendation to leave this tube in for approximately six weeks. over the next couple days, the patient's vasopressin was continuing to be decreased as the patient's blood pressure improved. his epinephrine was weaned off. he was resumed on his anticoagulation. heparin was started for atrial fibrillation. vancomycin and levofloxacin were discontinued at that time and his ventilator was weaned to cpap mode. on , the patient was weaned off his vasopressin. zosyn and heparin were being continued at that time. he was weaned from mechanical ventilator and extubated. the patient continued over the next few days in atrial fibrillation with a controlled ventricular response rate in the 80s to 90s, blood pressure which was stable and continued with aggressive pulmonary toilet. he had significant periods of confusion, worsening at night, but was ultimately transferred out of the intensive care unit to the telemetry floor on , postoperative day eighteen, where he was on two liter nasal cannula oxygen. his blood pressure was stable. he remained in atrial fibrillation with a rate in the 90s and continued with aggressive pulmonary toilet. the patient did require sitters while on the telemetry floor due to worsening agitation and confusion at night. the patient continued with diuresis and was tolerating that well. on the evening of , the patient was noted to have worsening hypoxia, with very weak cough effort. pulmonary toilet and nasotracheal suctioning did not improve his oxygenation and the patient essentially had a respiratory arrest at about 9:00 p.m. and was intubated. he was transferred back in to the cardiac surgery recovery unit at that time and underwent a bronchoscopy for which he was noted to have erythematous airways as well as moderate amounts of tan secretions. he underwent bronchoscopy the following day as well for secretion clearance. the patient had also become hypotensive with the reintubation and sedation required to facilitate the mechanical ventilator and was started on neo-synephrine drip. on , the patient was continued on bronchodilators. he was given some diamox for metabolic alkalosis, continued on flagyl and zosyn empirically for his cholecystostomy tube placement. tube feeds were continued. the patient had a neurology consultation at that time due to family's concern about speech deficit which he had prior to being intubated. their recommendations at that time were to continue anticoagulation for his atrial fibrillation, to put him on a statin drug for stroke prevention and to reevaluate him after extubating him again. over the next couple of days, he underwent slow wean of pressure support. he remained on neo-synephrine for some continued hypotension and remained on heparin for his atrial fibrillation. another bronchoscopy was performed on , where thick tan secretions were obtained. the patient was ultimately extubated again on , and has required aggressive pulmonary toilet to maintain a stable airway and oxygenation status. the following day the patient underwent a swallow evaluation by the speech therapy department here and it was noted at that time that he had nonfunctional swallow. it was their recommendation to maintain a strict npo status and place a percutaneous endoscopic gastrostomy tube for continued nutritional support and to work with him from a speech therapy standpoint after discharge from the hospital in a rehabilitation facility. the patient remains with some agitation which was worse at night. the neurology service did reevaluate the patient after extubation and found no significant aphasia or dysarthria at the time and felt that there was no further need for neurology intervention. psychiatry consultation was obtained on , due to continued confusion and it was their recommendation to use haldol as needed for severe agitation and also recommended to continue one to one sitters until the patient's mental status was more calm. on , general surgery consultation was obtained again. dr. saw the patient in consultation for percutaneous endoscopic gastrostomy placement. over the next few days, the patient remained being diuresed on diamox at this time due to metabolic alkalosis. on , percutaneous endoscopic gastrostomy was placed by dr. and the patient tolerated that procedure well. he was ultimately started on trazodone at night time for sleep and was significantly more calm the day after receiving the trazodone. he slept well the night prior to that. today, , the patient's mental status is much clearer with very intermittent periods of confusion and no agitation whatsoever. the patient remains hemodynamically stable and ready to be transferred to rehabilitation facility. most recent cultures on the patient include a gram stain of his sputum from , which revealed oropharyngeal flora, also had negative urine and blood cultures from that same day, and, of note, on , he had a rpr which was negative. that was checked at the recommendation of the neurology service. most recent laboratory values include a white blood cell count of 11.8, hematocrit 39.5, platelet count 216,000. sodium 141, potassium 4.5, chloride 104, co2 34, blood urea nitrogen 31, creatinine 0.8, glucose 114. inr 1.1, partial thromboplastin time 42.4. chest x-ray on , revealed small bilateral effusions with associated lower lobe bilateral atelectasis. the patient neurologically is alert and oriented and following commands appropriately. he moves all extremities without any apparent deficits although he has generalized weakness. his lungs are coarse rhonchi bilaterally and diminished bilateral bases. his coronary examination is irregular rate and rhythm. his abdomen is soft and nontender. he has a cholecystostomy tube in place with no surrounding erythema and he has a percutaneous endoscopic gastrostomy tube also in place and the site looks good for that as well. the patient's foley catheter was discontinued today and we are awaiting him to void. if he does not, his foley catheter will be replaced prior to transferring him to rehabilitation facility. his extremities are warm and well perfused with 1+ peripheral edema. medications on discharge: 1. flonase 110 mcg two puffs twice a day. 2. lansoprazole 30 mg p.o. once daily. 3. digoxin 0.125 mg p.o. once daily. 4. levofloxacin 500 mg p.o. once daily to continue for one more week for bronchitis and pulmonary prophylaxis. 5. albuterol nebulizer solution q4hours. 6. heparin intravenous drip presently at 700 units per hour. he is to stay on this while his coumadin is being advanced until his inr is approximately 1.7 to 1.8 range. his goal inr is about 2.0 to 2.5 for atrial fibrillation. 7. haldol 1 mg p.o. three times a day p.r.n. agitation. 8. metoprolol 25 mg p.o. twice a day, to be held for heart rate less than 65 or systolic blood pressure less than 90. 9. trazodone 100 mg p.o. q.h.s. 10. acetazolamide 250 mg p.o. q8hours times one more day and then his electrolytes should be rechecked to assess appropriate diuretic regimen. 11. acetaminophen 650 mg p.o. q4-6hours p.r.n. 12. coumadin 2 mg today, , and will likely receive 2 mg on , as well. his inr needs to be checked daily until he reaches a therapeutic dose. again, his target inr is 2.0 to 2.5. upon discharge from rehabilitation facility, it is our request that the coumadin be managed by the patient's primary care physician, hopes that he will be on a stable dose at the time of discharge. primary care physician is . . fop: the patient should follow-up with dr. at upon discharge from rehabilitation facility. the patient should follow-up with dr. at , for definitive treatment with likely removal of his cholecystostomy tube approximately the first week in . it is also the recommendation of the psychiatry consultation service here that the patient receive a psychiatric consultation in rehabilitation and dr. note will be sent along with his discharge paperwork from . discharge diagnoses: 1. aortic stenosis, mitral stenosis, status post aortic valve replacement, status post mitral valve replacement. 2. chronic obstructive pulmonary disease. 3. atrial fibrillation. 4. swallowing dysfunction. 5. tracheobronchitis. condition on discharge: good. the patient should undergo aggressive pulmonary toilet and chest physical therapy. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more extracorporeal circulation auxiliary to open heart surgery diagnostic ultrasound of heart insertion of endotracheal tube other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] open and other replacement of aortic valve with tissue graft closed [endoscopic] biopsy of bronchus open and other replacement of mitral valve with tissue graft monitoring of cardiac output by other technique transfusion of packed cells transfusion of other serum other percutaneous procedures on biliary tract diagnoses: thrombocytopenia, unspecified unspecified protein-calorie malnutrition atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation rheumatic heart failure (congestive) alkalosis acute cholecystitis mitral valve stenosis and aortic valve stenosis 

Answer: The patient is high likely exposed to