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: heparin agents attending: chief complaint: aortic valve abscess s/p cabg/avr major surgical or invasive procedure: - right thoracentesis - picc line in interventional radiology - placement of permenant pacemaker ( sigma dual chamber) - cardiac surgery 1. redo sternotomy. 2. redo coronary artery bypass grafting x4 with a reverse saphenous vein graft to the distal left anterior descending coronary artery; reverse saphenous vein double sequential graft from aorta to the first diagonal and first obtuse marginal coronary artery; as well as reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. 3. aortic root replacement with a 25 mm homograft with left coronary button re-implantation and oversewing of the right native coronary ostia. 4. mitral valve replacement with a 27 mm mosaic bioprosthetic valve. 5. endoscopic greater saphenous vein harvesting. - cardiac catheterization history of present illness: the patient is a 65-year-old gentleman who approximately a year ago underwent four-vessel coronary bypass grafting and aortic valve replacement with a st. mechanical prosthesis at in by dr. . the patient did well for many months but was noted to have fevers, chills and was diagnosed with staph epidermidis prosthetic aortic valve endocarditis with acute vegetation below the aortic valve and partial dehiscence of the valve, as well as severe mitral regurgitation and involvement of the mitral valve with aortic root abscess. cardiac cath here demonstrated that all of his vein grafts were totally occluded and his mammary to lad anastomosis had a 60%stenosis within it. the patient was admitted for preoperative work-up and management for possible redo cardiac surgery. past medical history: 1. hodgkin lymphoma (l preauricular per pt) - s/p xrt and splenectomy in 2. thyroid cancer - s/p thyroidectomy in 3. left cea 4. hypercholesterolemia 5. pci rca 6. cabg/avr (st. metal valve) social history: married, 2 kids, works at a toy company, occasional etoh, quit tobacco in . family history: mom alive at 84 - well; dad died at 80 with prostate cancer; 2 brothers - well. physical exam: admit pe vs: 96.4 hr 58 with second degree avb bp 86/56 94% ra sats neuro: a+ox3, mae, cn ii-xii intact. neck: supple, no jvd lungs: cta heart: rrr, nl s1-s2, iii.vi systolic murmur abd: benign skin: warm, dry ext: 2+ pulses discharge pe vs: 97.8 102 106/57 20 100% ra 83.3kg neuro: a+ox3, mae lungs: ctab w/ decreased bs right base heart: rrr, -murmur abd: soft, nt/nd, +bs ext: l evh c/d/i, calf site w/ mild erythema, -warmth. right four toes and left three toes blackend/purplish color. as well as left fingers with purplish discoloration. pulses present throughout. discoloration d/t thrombus believed to be from thrombocytopenia. pertinent results: echo there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is mildly depressed. a mechanical aortic valve prosthesis is present. the aortic prosthesis cannot be fully assessed but a 1cm somewhat mobile echodensity is seen on the lv side of the prosthesis in the subcostal views (clip#) c/w a vegetatiaon. the aortic valve gradient was not assessed. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no discrete vegetation is seen (does not exclude). mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. no discrete vegetation is seen (does not exclude). there is no pericardial effusion. cardiac catheterization 1. selective coronary angiography revealed a right dominant system with severe three vessel disease and occluded svg grafts. lmcahad a mid vessle 30% stenosis. the lad had a 50% lesion at s1 and an 80% lesion at d2. the dital vessel filled via lima. lcx was proximally occluded and the distal om filled via collaterals. rca was occluded in the mid-vessel. svg to rca, diagonal and om were all occluded. lima to lad was patent but there was a 60% lesion just proximal to the anastomosis. 2. aortography showed 3+ ai. 3. left ventriculography was deferred given endocarditis on the prosthetic valve. 4. limited hemodynamic assessment showed normal systemic aortic pressures. 5. fluoroscopy showed excessive motion of the prosthetic aortic valve. head cta 1. no acute hemorrhage or mass effect. 2. mild chronic microvascular infarction, as noted above. 3. no evidence of central or peripheral arterial aneurysms. please note that cta has limited sensitivity for peripheral mycotic aneurysms, for which conventional angiography may still be required for detection. 4. no significant arterial stenoses. chest/abdomen ct 1. single small solitary pulmonary nodule, for which 12- and 24-month followup ct chest examinations are recommended to ensure stability and/or resolution, in the absence of known malignancy. 2. transvenous pacer wire terminating in the right ventricle. 3. status post aortic valve replacement. 4. no definite evidence of septic emboli or abscesses. however, there are small bilateral perfusion defects in the kidneys which could relate to non- occlusive emboli. a similar appearance can also be seen in pyelonephritis. correlation with urinalysis is recommended. renal ultrasound the right kidney measures 12.5 cm and the left kidney 11.2 cm. both kidneys are morphologically normal without stones, hydronephrosis or solid mass. there are normal waveforms in the right lower, mid, and upper interlobar arteries and main renal artery. color doppler shows uniform perfusion of the right kidney. doppler evaluation of the left kidney was not possible due to the patient's difficulty with breath holding maneuvers. carotid duplex ultrasound less than 40% right carotid stenosis. no stenosis of the left carotid. le u/s 1. no dvt on the right. the basilic vein on the right is not visualized secondary to a picc line with overlying dressings which preclude assessment for the basilic vein. 2. residual left internal jugular vein non-occlusive thrombus. patent subclavian, axillary and basilic veins without thrombus. chest x-ray right picc line and permanent pacemaker remain in place. there has been prior median sternotomy and coronary artery bypass surgery. lung volumes are low, accentuating the cardiac silhouette and bronchovascular structures. there is persistent interstitial edema. more confluent opacities are again demonstrated at the lung bases, right greater than left adjacent to moderate right and small left pleural effusions. appearance of the base is slightly worse that could be accentuated by the lower lung volumes. 06:28pm glucose-121* urea n-24* creat-0.8 sodium-132* potassium-3.9 chloride-97 total co2-25 anion gap-14 06:28pm wbc-18.9* rbc-4.12* hgb-11.7* hct-34.1* mcv-83 mch-28.4 mchc-34.3 rdw-17.5* 06:28pm pt-24.2* ptt-34.7 inr(pt)-2.4* wbc-14.9 rbc-3.59 hgb-10.2 hct-32.6 mcv-91 mch-28.4 mchc-31.3 rdw-17.5 plt ct-392 05:33am pt-20.3*ptt-36.0*inr-2.0*plt-392 renal&glucose glucose-103 urean-21 creat-1.1 na134 k- cl-97 hco3-32 angap-9 brief hospital course: mr. was admitted to the on via transfer from center for further management of his endocarditis. he was transferred to the intensive care unit over the weekend for diuresis and management of his congestive heart failure. a transvenous pacer was placed for heart block. vancomycin was continued. as his platelets dropped to 52,000, a heparin induced thrombocytopenia (hit) assay was sent which was negative. as his conditioned worsened with increasing need for inotropes, it was decided to proceed more urgently with surgery. ciprofloxacin was started for a urinary tract infection. a cardiac catheterization was performed which revealed three vessel coronary artery disease with occluded vein grafts and a patent internal mammary to the left anterior descending. an echocardiogram was significant for 3+ aortic regurgitation 3+ mitral regurgitation and 2+ tricuspid valve regurgitation. his ejection fraction was noted to be 45%. on , mr. was taken to the operating room where he underwent a redo sternotomy, four vessel coronary artery bypass grafting, a bentall procedure, a mitral valve replacement with a 27mm mosaic valve, an left ventricular outflow tract repair and removal of a temporary pacer lead. please see operative report for details. postoperatively he was taken to the intensive care unit for monitoring. pressors were slowly weaned off. on , mr. neurologically intact and was extubated. gentle diuresis was initiated. on , mr. was taken to the electrophysiology lab where a dual chamber pacemaker was placed. coumadin was started for anticoagulation as he developed a left internal jugular and subclavian thrombosis. a repeat hit was sent which was again negative. the hematology service was consulted who felt that despite being negative for hit, he clinically had hit (heparin should not be used). it was also noted that his liver function studies were elevated which were then followed closely. his pacemaker was interrogated by the electrophysiology service which showed it to be functioning normally. on postoperative day five, mr. was transferred to the step down unit for further recovery. the physical therapy was consulted for assistance with his postoperative strength and mobility. zosyn was started for a right lower lobe consolidation. as he was slow to become therapeutic on coumadin, lepirudin was started as a bridge. the surgery service was consulted for ischemic toes due to thrombocytopenia. these were watched closely with the presumption that amputation would likely be necessary at some point. he was returned to the intensive care unit for lack of access and placement of a groin line. he developed some mild sternal drainage which slowly improved without evidence of infection. nystatin was started for thrush with good results. a picc line was placed under fluoroscopy for access in his right arm. repeat venous ultrasound continued to show thrombus in his left jugular, subclavian, axillary and basilic vein. an ankle-brachial index study was performed which was normal. anticoagulation was continued with a slow inr response. ultimately his inr became therapeutic on coumadin and lepirudin was discontinued. on post-op day seventeen he required a right thoracentesis in which 2600 cc of serosanguinous fluid was removed. later on this day he was transferred back to the csru d/t increasing somnolence and required closer monitoring. the following day he was transferred back to the sdu more alert and orientated. mr. continued to make steady progress and was discharged to rehabilitation on post-op day twenty-four. he will follow-up with dr. , cardiologist, primary care physician, surgeon, pacer device clinic, and infectious disease as an outpatient. coumadin will be continued for hit for 6 months. medications on admission: home meds: coumadin, lipitor, flovent, atrovent, aspirin, protonix meds at transfer: synthroid, lipitor, flovent, atrovent, aspirin, vancomycin, rocephin, protonix, ativan discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. cilostazol 100 mg tablet sig: one (1) tablet po bid (2 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 6. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po three times a day. 10. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 12. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 13. vancomycin 500 mg recon soln sig: one (1) recon soln intravenous q 12h (every 12 hours): check trough weekly. 14. gabapentin 400 mg capsule sig: one (1) capsule po tid (3 times a day). 15. furosemide 40 mg tablet sig: 1.5 tablets po twice a day. 16. warfarin 3 mg tablet sig: one (1) tablet po once (once): please check inr goal inr 2-2.5 for dvt . 17. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po bid (2 times a day). 18. metoprolol succinate 50 mg tablet sustained release 24 hr sig: 4.5 tablet sustained release 24 hrs po bid (2 times a day). discharge disposition: extended care facility: on - discharge diagnosis: aortic abscess/coronary artery disease/mitral regurgitation s/p bentall procedure, coronary artery bypass graft x 4, aortic and mitral valve replacement complete heart block s/p placement of permenant pacemaker thrombocytopenia/clinically had hit (lab panel was hit antibody negative) pmh: mobitz type i av block, hypercholesterolemia, thyroid cancer w/ thyroidectomy, s/p cabgx4/avr , splenectomy in , left carotid endarterectomy in , hodgkins lymphoma with radiation in discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5)no lifting greater then 10 pounds for 10 weeks. 6)no driving for 1 month. followup instructions: follow-up with dr. in 1 month. ( follow-up with pcp . in 2 weeks. follow-up with local cardiologist, dr. for pacemaker check in or dr. office has been called and will call you to schedule the appointment. follow up with dr. ( surgeon) in 1 week. provider: , md phone: date/time: 10:00 labs: q weekly (wednesday) vancomycin trough, cbc w/ diff, lft, cr fax results to please first draw picc line needs to be removed under fluoro please schedule, and pacemaker checked after picc line removed. pt/inr for dvt goal inr 2-2.5 first draw call all providers for appointments. procedure: venous catheterization, not elsewhere classified extracorporeal circulation auxiliary to open heart surgery coronary arteriography using two catheters left heart cardiac catheterization diagnostic ultrasound of heart other and unspecified coronary arteriography (aorto)coronary bypass of four or more coronary arteries thoracentesis initial insertion of dual-chamber device initial insertion of transvenous leads [electrodes] into atrium and ventricle insertion of temporary transvenous pacemaker system insertion of temporary transvenous pacemaker system open and other replacement of aortic valve with tissue graft resection of vessel with replacement, thoracic vessels aortography pulmonary artery wedge monitoring open and other replacement of mitral valve with tissue graft transfusion of packed cells transfusion of other serum other operations on vessels of heart transfusion of platelets phlebography of other specified sites using contrast material operations on other structures adjacent to valves of heart infusion of vasopressor agent diagnoses: pneumonia, organism unspecified coronary atherosclerosis of native coronary artery pure hypercholesterolemia mitral valve disorders urinary tract infection, site not specified congestive heart failure, unspecified coronary atherosclerosis of autologous vein bypass graft atrioventricular block, complete bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site other acquired absence of organ other complications due to other vascular device, implant, and graft acute and subacute bacterial endocarditis anticoagulants causing adverse effects in therapeutic use atherosclerosis of native arteries of the extremities with gangrene other and unspecified coagulation defects infection and inflammatory reaction due to cardiac device, implant, and graft personal history of malignant neoplasm of thyroid 

Answer: The patient is high likely exposed to