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: benadryl / winrho sdf / heparin agents attending: chief complaint: sob major surgical or invasive procedure: - flexible bronchoscopy and 8-0 portex tracheostomy tube placement. - aortic valve replacement with a size 21 magna tissue valve, mitral valve replacement with a size 25 bovine tissue valve, and tricuspid valve repair with size 30 ring. history of present illness: this 68-year-old patient with severe aortic stenosis, mitral stenosis and mitral regurgitation plus significant tricuspid regurgitation with normal coronary arteries with preserved ventricular function was electively admitted for triple valve surgery. the major significant history was history of cirrhosis with the child b bordering on c calcification occasionally with the prior gastrointestinal bleeding and esophageal varices and splenomegaly and also idiopathic thrombocytopenia. because of the co-morbidities, she was optimized for surgery for quite a few months where she underwent a recurrent tapping of the ascites and also had treatment for the thrombocytopenia by way of steroids and platelet infusion and immunoglobulin injection. once the liver function was optimized as best as possible almost to a child a bordering on b status and some response of the platelet count to hematological management, further discussion was had with the patient about the high- risk of the surgery. the patient was very keen to proceed with the operation because of the recurrent admissions for congestive cardiac failure and a very poor quality of life and was willing to take the high risk operation. she was electively admitted for surgery. on the day before surgery, she had further dose of hemoglobin given to increase the platelet count to above 100,000. this was done successfully and the patient was taken to operating room. past medical history: 1. severe valvulopathies, including at least moderate aortic stenosis with estimated aortic valve area of 1 cm2, mixed mitral valve disease with moderate mr and mild ms (mva 1.5-2.0 cm2), followed by dr. . felt to be a poor candidate for a complex multi-valve surgery. 2. severe secondary pulmonary hypertension, on home oxygen therapy at home 2.5 liters per minute. her last pulmonary pressures were 53/25/37 on catheterization in . portopulmonary hypertension is felt to be a contributor. 3. congestive heart failure, echo with preserved systolic function in albeit in setting of mitral regurgitation. 4. longstanding diabetes type 2, last hemoglobin a1c 5.7 on . 5. liver cirrhosis, followed by dr. , presumed secondary to nash with contribution from cardiac cirrhosis, complicated by ascites, splenomegaly, and varices on egd (grade 2 and one grade in the distal 3-4 cm of the esophagus) 6. itp, compounded by severe liver disease and splenomegaly, followed by dr. . no response to ivig, low and high dose prednisone therapy, and life-threatening intravascular hemolysis following winrho. on no therapy at present. 7. osteoporosis, on fosamax. 8. basal cell carcinoma. social history: she lives alone at home, with extensive vna services (telemonitoring). her daughter is very involved in her care. she used to work in consumer services, has been unable to work in recent months. family history: not reviewed with patient during this admission. physical exam: pe 98.9 90/48 98 20 99ra gen: laying in bed, non-toxic, well-appearing heent: ncat, mmm neck: supple, jvd ~ 9 cm, no carotid bruits chest: rales in lower of lung fields cvs: rrr, grade ii/vi sem @ rusb with radiation to carotids and clavicle, blowing hsm @ apex abd: soft, nabs, nt,no rebound/gaurding but marked distended (ascites) extrem: no c/c; + (b)le edema. rle erythema along leg extending to foot neuro: cn ii-xii intact msk: no joint effusions, normal rom pertinent results: 02:45pm plt smr-very low plt count-62*# 02:45pm pt-14.5* ptt-30.9 inr(pt)-1.3* 02:45pm wbc-5.9 rbc-2.88* hgb-8.6* hct-24.8* mcv-86 mch-29.9 mchc-34.8 rdw-18.9* 02:45pm glucose-229* urea n-29* creat-0.8 sodium-126* potassium-5.0 chloride-89* total co2-31 anion gap-11 - ultrasound and paracentesis the liver is shrunken and slightly nodular in appearance consistent with cirrhosis. no dilated ducts are noted. the left, middle and right hepatic veins are patent. the ivc is patent. the left main, right anterior and right posterior portal veins are patent. flows are in appropriate directions. there is a moderate amount of ascites, and a spot was marked in the left lower quadrant for a paracentesis to be done by the clinical service. echo pre-bypass: 1. the left atrium is markedly dilated. no atrial septal defect is seen by 2d or color doppler. 2. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. 3. the right ventricular cavity is mildly dilated. there is mild global right ventricular free wall hypokinesis. 4. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (area <0.8cm2). no aortic regurgitation is seen. 6. the mitral valve leaflets are severely thickened/deformed. there is severe mitral annular calcification. there is a minimally increased gradient consistent with trivial mitral stenosis. moderate to severe (3+) mitral regurgitation is seen. 7. moderate to severe tricuspid regurgitation is seen. post-bypass: for the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. a well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion. given suboptimal echo windows gradients could not be obtained across the aortic valve. no aortic regurgitation is seen. 2. a well-seated bioprosthetic valve is seen in the mitral position with normal leaflet motion and gradients (mean gradient = 9 mmhg). co was 8 l/min no mitral regurgitation is seen. 3. a well-seated tricuspid ring is seen. trace to mild tr was seen. mean gradient across the valve is 5 mm of hg. 4. lv function is unchanged.. rv function is mild to moderately depressed. 5. aortic contours appear intact post decannulation. head ct no acute hemorrhage or mass effect. chronic lacune left thalamus. chest/abdomen ct scan 1. status post cabg for mitral and aortic valve replacements. moderate pleural effusion are present bilaterally. compressive atelectasis are also present at both lung bases. 2. significant amount of ascites is noted within the abdomen. there is hyperdense fluid within the pelvis suggesting the presence of the hemoperitoneum. left rectus sheet hematoma is also noted. 3. small liver and multiple collateral vessels and enlarged spleen suggesting cirrosis. 4. cholelithiasis with no evidence of cholecystitis. 5. pulmonary arterial hypertension with main pulmonary artery measuring 4.2 cm. brief hospital course: ms. was admitted to the on for surgical management of her valve disease. after extensive discussion, ms. agreed to surgery despite the fact that it would be a high risk surgery. she was prepared for surgery by diuresis and multiple ultrasound guided paracentesis by the liver service. ivig was given prior to surgery given he history of itp. the diabetes service was for assistance with her diabetes management. on , ms. was taken to the operating room where she underwent an aortic and mitral valve replacement using tissue valves and a tricuspid valve repair with a ring. please see operative note for further details. postoperatively she was taken to the intensive care unit for monitoring. given the complexity and length of her postoperative course, the remainder of her discharge summary will be divided into systems. cardiac: postoperatively her pressors and inotropes were slowly weaned. she remained volume overloaded and cautiously diuresed. she developed atrial fibrillation for which amiodarone was started. she continued to have paroxysmal runs of atrial fibrillation however beta blockade was used in place of amiodarone. as she was already auto-anticoagulated given her liver failure, no further anticoagulation with heparin or coumadin was used. on , ms. became septic and pressors were resumed. on , ms. developed a junctional bradycardia and her diltiazem and beta blockade were held. her rhythm later returned to sinus rhythm and her cardiac medications were slowly resumed. as her sepsis picture resolved, her pressors were slowly weaned off without issue. she continued to have atrial fibrillation throughout her postoperative course and diltiazem sufficiently controlled her rate. liver: the hepatology followed ms. throughout her hospital course. she required several therapeutic paracentesis for drainage of ascites fluid. albumin and lactulose were given therapeutically. rifaximin was also used prophylactically and will continue per the hepatology service. renal: postoperatively, ms. developed renal failure with a rising creatinine. the renal service was who followed her closely throughout the remainder of her hospital stay. as the concern was for hepatorenal syndrome, midodrine and octreotide were used for blood pressure support. her electrolytes were closely monitored and her medications were renal dosed. epogen was used for anemia. slowly her renal function began to improve. aldactone was later used in place of lasix for diuresis. on , ms. renal function again began to deteriorate. as her bun/creatinine continued to rise in the setting of oliguria and volume overload, cvvh (hemodialysis) was initiated on . a tunnelled line was placed on for hemodialysis. she tolerated hemodialysis well and her estimated dry weight was 86.5kg. hematology: postoperatively ms. became thrombocytopenic. a hit assay was sent which returned positive and a hematology consult was obtained. anticoagulation was started with argatroban as a bridge to coumadin. as her platelets continued to fall given her itp and her continued anemia, it was decided not to anticoagulate her further. she was transfused with packed red blood cells for postoperative anemia. interestingly, a serotonin release assay for hit returned negative thus heparin could be used for anticoagulation. over time, her platelets continued to fall which was thought to be a result of infection superimposed on her itp. ivig was given with platelets for treatment. diabetes: the diabetes service was and followed ms. throughout her postoperative course. an insulin drip was maintained postoperatively to regulate her blood sugars while intubated. as she recovered and was fed via tube feeds as well as an oral diet while her passe muir valve was in place, lantus was used at bedtime while a regular insulin sliding scale was also used. respiratory: on , ms. neurologically intact and was extubated. she slowly decompensated during the day and needed to be reintubated for respiratory failure later that day. she went on to tolerate short courses of cpap however was unable to fully wean from the ventilator due to hypercarbia and acidosis. she was extubated again on . she did well until her level of consciousness began to decline. she was electively re intubated on . the thoracic surgery service was for placement of a tracheostomy tube. this was successfully placed on . her vent was slowly weaned as she tolerated. a passe muir valve was placed which she was able to tolerate for short periods of time. infectious disease: ciprofloxacin and flagyl were started for leukocytosis. she was cultured and found to have a klebsiella urinary tract infection as well as c. difficile. she later developed gram positive bacteremia and the infectious disease service was . a single dose of vancomycin was given and it was recommended to not treat until repeat blood cultures were obtained. her repeat blood cultures were negative. a sputum culture on grew serratia marcescens and vancomycin and cefepime were started. ciprofloxacin replaced the former two medications when sensitivities returned. flagyl was started for treatment of c. diff colitis. by the time of discharge, she had completed all antibiotic treatment and had no active infectious issues. rifaximin was continued prophylactically. neurologic: on , ms. level of consciousness declined. an urgent head ct was obtained which showed no acute events. given the normal ct scan of her head, it was suspected that her renal and liver function were worsening. with antibiotic treatment and dialysis her neurologic status cleared. anti anxiolytics and an antidepressant were prescribed for her depressed state. nutrition: tube feeds were started while she was intubated for nutritional support. when extubated, she began an oral diet however was unable to adequately nourish herself. tube feeds were resumed on . as she improved, a swallowing evaluation was performed which showed her able to take solids. as she was only able to take a small amount of solids, her tube feeds were continued for nutritional support. wound care: the wound care nurse for assistance with her skin breakdowns on her bilateral lower extremities, left upper extremity and back. she was evaluated daily and efforts were made to maintain the integrity of her skin and promote healing of her wounds. ms. continued to make steady progress. the physical and occupational therapy service worked with her daily to help increase her strength and mobility. on postoperative day 43, she was discharged to rehabilitation for further recovery. she will follow-up with dr. , her cardiologist, the renal service, the liver service and her primary care physician as an outpatient. hemodialaysis will be continued at rehabilitation as well as her vent wean. medications on admission: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. nadolol 20 mg tablet sig: one (1) tablet po daily (daily): take at 5 p.m. 3. insulin glargine 100 unit/ml solution sig: seventy five (75) units subcutaneous at bedtime. 4. insulin lispro (human) 100 unit/ml solution sig: sliding scale subcutaneous as directed. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 7. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 8. ropinirole 0.25 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)) as needed. 9. fosamax 70 mg tablet sig: one (1) tablet po once a week. 10. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 11. ampicillin-sulbactam g recon soln sig: three (3) g injection q8h (every 8 hours) for 6 days. 12. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: & rehab center - discharge diagnosis: as/mr/tr s/p avr/mvr/tvr type 2 diabetes pulmonary htn chf steatohepatitis (non-alcoholic) cirrhosis renal failure respiratory failure af wound infection c. difficile skin breakdown pulmonary edema sepsis ascites thrombocytopenia discharge condition: stable md 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 enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage temporary tracheostomy open and other replacement of aortic valve with tissue graft open and other replacement of mitral valve with tissue graft transfusion of packed cells transfusion of other serum open heart valvuloplasty of tricuspid valve without replacement transfusion of platelets injection or infusion of immunoglobulin infusion of vasopressor agent diagnoses: acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified cirrhosis of liver without mention of alcohol diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver acquired coagulation factor deficiency unspecified septicemia unspecified protein-calorie malnutrition severe sepsis portal hypertension chronic airway obstruction, not elsewhere classified atrial fibrillation other chronic pulmonary heart diseases rheumatic heart failure (congestive) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease personal history of other malignant neoplasm of skin cellulitis and abscess of leg, except foot long-term (current) use of insulin osteoporosis, unspecified intestinal infection due to clostridium difficile hepatic encephalopathy esophageal varices in diseases classified elsewhere, without mention of bleeding diseases of tricuspid valve immune thrombocytopenic purpura splenomegaly mitral valve stenosis and aortic valve stenosis other chronic nonalcoholic liver disease 

Answer: The patient is high likely exposed to