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: patient recorded as having no known allergies to drugs attending: chief complaint: atrial fibrillation and mitral regurgitation major surgical or invasive procedure: avr (25mm - pericardial tissue valve), mv repair (28mm annuloplasty band),maze procedure, closure of atrial septal defect and an ascending aorta replacement using a 28mm gelweave graft. of present illness: mr. is a 64 year old gentleman with a long standing history of mitral regurge and atrial fibrillation despite ablation therapy and multiple antiarrythmic drugs. his atrial fibrillation is generally exacerbated by exercise and accompanied by significant dyspnea. his most recent echocardiogrma showed 2+ aortic regurgitation, 1+ mitral regurgitation, 1+ tricuspid regurgitation, a dilated left and right atrium, a mildly dilated aortic root and an ejection fraction of 55%. a cardiac catheterization did not show any significant coronary artery disease. due to the progression of his disease and debilitating symptoms, mr. was referred to dr. for surgical management. past medical history: atrial fibrillation mitral regurgitationpast hernia repair social history: mechanical engineer who lives in with wife. quit smoking 30 years ago. rarely uses alcohol. family history: mother died at age 80 from an aortic aneurysm. father died at age 80 from congestive heart failure. sieter age 65 status post mitral valve replacement at age 60. sister age 67 with diabetes. physical exam: vital signs: hr 60 irregularly irregular bp (l) 110/74 (r) 114/80 ht 69" wt 160 lbs general: no apparent distress, well developed well nourished. skin: warm, dry, no lesions heent: perrl, eomi, anicteric sclera, oropharynx benign. neck: supple, no lymphadenopathy, no thyromegally chest: clear lungs heart: irregularly irregular rhythm, iii?vi systolic murmur with quiet diastolic murmur. abdomen: soft, nontender, nondistended, normoactive bowel sounds. ext: no clubbing, cyanosis or edema. no varicosities. 2+ pulses throughout extremities. no femoral or carotid bruits. neuro: cranial nerve ii-xii grossly intact, no focal deficits. pertinent results: preop labs: wbc-4.0, hct-34.3, plt-168, na- 138, k-4.1, bun-0.7, creat-1.0. lft's within normal limits 06:35am blood wbc-9.4 rbc-3.35* hgb-10.5* hct-30.1* mcv-90 mch-31.4 mchc-35.0 rdw-14.9 plt ct-566* 09:35am blood pt-16.8* inr(pt)-1.8 09:35am blood glucose-185* urean-24* creat-1.0 na-137 k-4.4 cl-105 hco3-23 angap-13 cxr status post avr. cardiomegaly with bilateral pleural effusion. healed fracture of the ribs. video oropharyngeal swallow oral phase is notable for moderately impaired bolus formation and control. there is premature spillover into the pharynx with all consistencies. during the pharyngeal phase of swallowing, there is a mild delay in swallow initiation. laryngeal valve closure was impaired causing penetration and aspiration. penetration occurred during and after the swallow and worsened as the study went on. aspiration of all consistencies occurred after the swallow due to penetration. there was no spontaneous cough. pathology a. aortic valve leaflets: valve leaflet with myxoid degeneration and calcification. b. aorta: segment of vessel wall with myxoid change. echo the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall systolic function is good (lvef >40%). right ventricular chamber size is normal with mild global free wall hypokinesis. a bioprosthetic aortic valve prosthesis is present. no definite aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is a small (<=1.0cm) circumferential pericardial effusion. no right ventricular diastolic collapse is seen. ekg atrial fibrillation 100. modest nonspecific inferior t wave changes. since previous tracing of , no significant change ospital course: mr. was admitted to the medical center on for surgical management of his heart disease. he was taken to the operating room where he underwent an aortic valve replacement utilzing a 25mm pericardial prosthesis, a mitral valve repair using a 28mm annuloplasty band, a maze procedure, an ascending aorta replacement using a 28mm gelweave graft and an atrial septal defect closure. postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. he was coagulopathic with a high chest tube output requiring blood products. this slowly resolved without issue. on postoperative day one, mr. neurologically intact and was extubated. the electrophysiology service was consulted for assistance with his current rapid rhythm of atrial fibrillation alternating with atrial flutter. his previous antiarrythmic dofetilide was resumed but later switched to beta blockade for rate control. a follow-up appointment was scheduled in weeks. coumadin and heparin were started for anticoagulation. mr. remained hypertensive neccessitating the use of intravenous nitroglycerin which was slowly weaned off over three days. he developed thick, copius secretions requiring large amounts of oxygen and bipap therapy. he was however able to mobilize these secretions quite well. the physical therapy service was consulted for assistance with mr. postoperative strength and mobility. his secretions slowly decreased and his atrial fibrillation became rate controlled. on postoperative day six, mr. was transferred to the cardiac surgical step down unit for further recovery. he was gently diuresed towards his preoperative weight. mr. seemed to develop some coughing while drinking thin liquids as well as a rsspy voice. he developed a fever for which he was pancultured and placed on zosyn and vancomycin. he developed respiratory distress in the setting of rapid atrial fibrillation and was transferred back to the cardiac surgical intensive care unit on for monitoring. natrecor was started for adecreased urine output with good effect. dofetilide was resumed for rate control. sputum cultures returned positive for enterobacter suggesting an aspiration pneumonia. his vancomycin was discontinued and zoysn was continued with gradual improvement. a speech and swallow consult was obtained and a bedside exam was suggestive of aspiration with possible vocal chord paralysis. the otolaryngology service was consulted and a video swallow study was obtained. this revealed a small amount of granulomatous tissue on the vocal chords and aspiration with thin and thick liquids likely due to his deconditioned status. a nasogastric feeding tube was placed and tube feeds were started. mr. became somewhat confused where he self removed his foley and intravenous lines. a sitter was assigned to his bedside at night for close observation. the neurology service was consulted who suspected a toxic, metabolic or infectious source of his confusion. seroquel was started nightly for agitation however he had further confusion with this and was thus was switched to librium with good effect. mr. nocturnal confusion continued to improve thus confirming a likely sleep/wake cycle disturbance. on , a repeat video swallow was performed which showed improvement of his swallowing ability however he continued to be unable to fully protect his airway. with strict aspiration precautions taken, mr. was able to swallow and clear the aspirated material during the study. a repeat video swallow was recommended in 1 week to see if diet can be safely advanced. tube feeds and supervised oral intake was continued. as he continued to do well with oral intake, his diet was slowly advanced to include thin liquids. the ear, nose and throat service performed a videostrobe study which showed incomplete closure of the true vocal chords due to bowing. no granuloma was seen. with teaching to cough following a swallow, all aspirates were cleared. voice therapy was recommened as an outpatient. mr. respiratory issues quickly improved. he was able to tolerate oral intake with strict aspiration precautions. his heart rate improved to a rate controlled atrial fibrillation. mr. continue dto make steady progress and was discharged to his home on . he will follow-up with dr. , his cardiologist, the electrophysiology service, the speech and swallow service and his primary care physician as an outpatient. medications on admission: acebutolol 200mg twice daily lisinopril 10mg twice daily\ paxil 10mg once daily dofetilide 500mg twice daily coumadin xanax 0.25mg as needed discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. disp:*1 mdi* refills:*0* 4. sertraline hcl 50 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. warfarin sodium 1 mg tablet sig: five (5) tablet po daily (daily) for 3 days: then vna to draw inr and call results to dr. office goal inr 2-2.5. disp:*100 tablet(s)* refills:*0* 7. chlordiazepoxide hcl 5 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 8. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* 9. dofetilide 500 mcg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: s/p avr(#25 ce pericardial)/mv repair(#28 annuloplasty band)/maze/ao dissection repair(#28 gelweave graft) prolonged icu stay, swallow dysfxn pmh:mr, ar, afib, hernia repair discharge condition: good discharge instructions: keep wounds clean and dry. ok to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds followup instructions: dr in weeks dr in weeks dr in 4 weeks repeat swallow (scheduled) procedure: extracorporeal circulation auxiliary to open heart surgery diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances excision or destruction of other lesion or tissue of heart, open approach open and other replacement of aortic valve with tissue graft resection of vessel with replacement, thoracic vessels other and unspecified repair of atrial septal defect transfusion of packed cells open heart valvuloplasty of mitral valve without replacement transfusion of other serum diagnoses: cardiac complications, not elsewhere classified atrial fibrillation mitral valve insufficiency and aortic valve insufficiency rheumatic heart failure (congestive) pneumonitis due to inhalation of food or vomitus dissection of aorta, thoracic acquired cardiac septal defect other diseases of vocal cords disruption of 24 hour sleep wake cycle, unspecified 

Answer: The patient is high likely exposed to